Forensic Document Information
Background
Clinical notes and recording communications with clients have a role to play in our services.
Clinicians have responsibility for clinical notes and rights to know how the notes are used within the health system in prison. The client has a right to access their own records so content should be respectful, evidence-based and concur with practitioner’s professional body confidentiality procedures. Client notes and communications can also be a resource within the wider prison healthcare team because they illustrate how and when the work has been done with attention to due processes to keep the client safer and in their best interest (evidence –based practice).
History of notes – read them
Is this the first episode of care? Have you read the previous notes to get an understanding of the history with help of the client, to understand more about their patters of wellbeing and risk? Have there been historic risks flagged on System 1, or if seen previously by Atrium on their CORE record.
121 and Assessment Sessions
In engaging with the client in Assessment and 121 sessions we need to mindful of No access visits, DNA’s and communications with the client and wider services we work with.
Appointment letters are sent out for each appointment booked with the client, this is proven to ensure clients know they are to be seen, are able to show appointments to other professionals to ensure they are available for the appointment, and also provide safety and risk reduction. With this DNA’s or No Access visits are reduced.
Definitions and Recording of Appointments
- 121 finished- recording on S1 ledger a completed sessions with clients, and on their journal with effective clinical notes, ensuring their next appointment or discharge is recorded with the relevant letter.
- DNA- when the client is unwell or refuses to engage. Record on system one on the clinician ledger, and document reason for DNA on client’s journal with next appointment date and letter recorded.
- No Access Visit – when both yourself and client are available for the appointment, however prison regime prevents session from going ahead, some examples of this are no rooms available, lockdown, officer not available or refuses to unlock client, and legal or social visit. Record on system one on the clinician’s ledger, and document reason for No Access visit on client’s journal with next appointment date and letter recorded.
What do practitioners write?
Make sure to keep client confidentiality in mind when recording session notes – only record necessary details on S1. All contact with clients, and discussions with Atrium, Healthcare, Prison or Other Prison Contracted Department staff that directly relates to a client’s risk must be recorded in System One. This includes Atrium procedure of sending appointment letters to the client for their weekly sessions.
- Client’s risk assessment and wellbeing; safety planning amendments and any actions
- Always include CORE scores for risk/total scores and how these scores have been understood in your assessment or risk planning
- Homework if appropriate reviewed and set; resources sent
What client took from the session and consideration of progress towards goals. Changes or additions to formulation. - Plans for next session
- Date for next session
- Upload appointment letter for next session
- Any actions in between session e.g., speak to supervisor safeguarding risk discussion
- Other as relevant.
Final session notes may be longer to include:
- A summary of risk
- Engagement with further support, if any.
- Reporting professional network being informed of the closure of the work. See Discharge policy and guidance on CORE.
When can we share notes?
If a request is made for you to share notes these are to be discussed with Clinical Lead Becky Hall, prior to any disclosure (please see disclosure and confidentiality process and policies).
For safeguarding concerns and professional partner information sharing on specific plans or safety plans, check with your supervisor and the client, where possible before sharing client information.
All requests to access the patient’s information from parole boards, solicitors after release and the client themselves should go through Oxleas/Practice Plus services, after release this can be accessed by calling Oxleas/Practice Plus Administration department for a formal request. As per our confidentiality agreement Atrium will not confirm or deny a client has been accessing the service until such a time client permission is gained.
| Last Review Date: | August 2023 |
