Client Records

Effective date: September 30, 2011

Revised January 2018

Relevant Legislation:

Not applicable to this policy.

Intent:

The purpose of records is:

• To provide an accurate account of the content and process of service as a means to assist in the planning and delivery of service.

• To provide the client with information they may request about themselves and the service provided, in accordance with privacy legislation.

• To provide information to assist others when the person providing the service is unavailable.

• Provide information if additional service is requested at a later date.

Documentation of service to clients is necessary to ensure that LOFT standards are being met. Client records sufficiently document assessments and the nature and extent of the service provided.

LOFT maintains accurate, up to date and confidential records for all clients except for those receiving anonymous service (i.e. needle distribution, outreach etc.)

Definitions:

Not applicable to this policy.

Policy:

Content:

All entries into records shall be dated with time of entry, legible and contain the name of the staff person who made the entry clearly indicated.  Full statements are to be used and abbreviations are to be avoided.

Records contain only information that is needed to document and support the direct service(s), the safety of the staff and other and to provide statistical information for planning purposes.

All consent to release information forms will be kept in the file and all contacts with third parties in respect of a client are to be documented in the client’s record.

All interactions with clients should be documented in the central database including the purpose of the interaction and outcome.

Client notes are to be completed by the appropriate staff within five working days of the client contact or shorter period if determined by director.

 

Procedures:

See program manual.