Good Practice Guides | Clinical notes on System 1/ Record keeping

Clinical notes on System 1/ Record keeping 

Appendix to Record Keeping Policy | Atrium Prison Counselling Service

Process on How to Keep Clinical Records on S1 and Check-in Process and Record Keeping

When we are writing our notes, there are a few things we need to hold in mind.

1. If I were suddenly not able to see my clients, would another clinician be able to understand where we were in the counselling sessions, how my clients present, what we were addressing in sessions and any current or future actions that I was undertaking and why.
2. Risk, have I addressed all risk presented in sessions, either through their explicit recording through CORE, or through their presentation. Have I documented all risk, and have I documented all actions I have taken based on presenting risk.
3. Have I completed all boxes within the template, even if they are not applicable, have I put n/a in box.

 

Within the Atrium session template there are 3 sections to be completed

• Atrium Practitioner Notes
• Current State/Risk
• CORE Assessments.

Each of these sections have either tick boxes or boxes to input written records, they ALL need to be completed each session.

 

Atrium Practitioner Notes

• Type of intervention drop down box- Choose which intervention this was for. Assessment, 121 session or Check-in.
• Confidentiality form signed- Tick this box at assessment to show confidentiality and contract have been discussed and the client has signed this, (this is a new box added to show contract and confidentiality has been discussed).
• Consultation- tick this box to show this was a healthcare appointment and was attended.
• Review Notes – Clinical Session notes should be placed in this box. Usually in the below format
• Atrium Counselling Session Attended, DNA or No Access
• Overview of what was discussed in session, if DNA or No Access if you did speak with client, what was said and agreed for rebooking.
• If assessment, short formulation, and plan for upcoming sessions
• Review of wider team intervention, if spoken about, inclusive of prison side
• Any agreed between session work or information you provided for client based on presenting issue.
• If final session client’s presentation regarding this and any agreement for ongoing work or referrals to other teams.
• Tick next session booked and date next session, you can open your ledger from here and book this immediately.

Current State/Risk

• Acct Status- Complete with either Open ACCT, Post closure ACCT or N/A
• Next appointment with Atrium- input either here or in previous section
• Brief overview of current state – this is an overview description of their state relating to their presentation,

e.g., Client presented withdrawn in session and reported feeling anxious and depressed both on Core form and verbally throughout session.

In this box you can also elaborate on personal hygiene, level engagement in session if unusual or linked to specific issues. Here always record any increase in issues they are reporting. If they presented well in session:

e.g., Client was clear and focused throughout session, engaged well with what they wished to focus on. No concerns currently regarding client presentation.

• Action plan, this is relating to further sessions, care plans, or referring to her services if required. For instance, if there is no change or any actions, complete with: To continue sessions.
• Risk factors. If no risk: No risk to self or others reported or observed throughout session/at time of session. If risk- outline all risk presented, always write, the client reported, when risk is discussed, we cannot put opinion, if we think something we have to address this within sessions and get the client input during session. If risk is future based, we must also report this here.
• Action taken regarding risk: Outline any actions taken to support client with the risk reported. This includes drug use, altercations on wing, as well, self-harm and suicidal ideation. If you are unsure what actions to take always contact Alex Wyld (Clinical Lead) via email or phone to discuss Case Management of risk and we can together go over what, if anything, is needed to put in place. As with risk actions, ensuring steps taken such as ACCT documents, observation book recording, Nomis updates and Security reports are completed as required.

 

CORE Assessments

• Input every session the CORE form they have completed. The information on the CORE form should back up all you have written in your notes and risk. If there is risk noted on CORE form and not in notes this needs to be actioned. If there is risk noted in notes and not on CORE form this should be highlighted in notes and the discussion you have had with your client regarding this must be recorded.

 

Check-in process

During triage of referral tasks on S1, occasionally we will need to provide check-ins, this might be to provide the client with some information e.g. support for panic attacks, or it might be to enquire with them if they wish to receive counselling as it is not clear from the referral, or if they have an ABI or mental health illness and if it is not clear of stability on paper an interaction would inform us more about if they would be able to engage effectively.

Lorna or I identify those requiring check-ins from the referral process.

1. Lorna will write up on white board in office client prison number under the check-ins received from referrals.
2. When a clinician has free space meaning they have time to provide check-in, please write initials next to the prison number and book the client in on the check-in ledger.
3. Check-in on the client.
4. Go see client on wing, if they in their cell, ask for them to be unlocked for a brief conversation. Introduce yourself, explaining who you are and where you are from and explaining why you are there. Ask them the question from the check-in email and would they like to be added to the counselling waiting list.
5. During the conversation we can enquire as to some of their issues to ensure the referral is correct, whilst recognising that you are speaking with them on the landing, we can ask if they are comfortable speaking with us in more detail about risk to self, there, if they say no, we would need to arrange perhaps moving to another area of the landing away from others or into a room if we have checked risk to others/females etc and have notified an officer. We ask regarding their risk to self or others, suicidal ideation, self-harm etc.
6. If any risk/vulnerability is identified, a more detailed conversation is required in a more confidential environment and decision whether an ACCT is to be opened.
7. Check-ins are always guided by questions relating to clients need and want for counselling, risk assessment based on direct questioning and following up with any risk. If they enquire regarding any other services such as OMU or prison related things, direct them to officers, or the CMS to refer themselves.

 

4. Finish the client on the check-in ledger and document client notes on the Atrium template, All the fields in the template must be completed, apart from the next session and CORE(although in body of notes you would input that they would be booked in for assessment when a slot becomes available) Always start your session notes for whatever interaction with clients with Atrium Counselling Service, always complete check-ins, assessments and session under our template to ensure all other S1 users know what service the notes are from. During a check-in everything bar the next session and Core form sections will be completed, you will still be writing clinical notes, presentation, review of risk and actions. putting it as a check-in, completing the 1^st and 2^nd pages, and ignoring the CORE form section.
5. Put a tick next to the client number on the white board to show it has been completed.
6. Email me and Lorna with the outcome of the check-in so we can complete and process the referral with the information received from the check-in.