What Are Case Notes?
As a package, case notes represent a complete record of your dealings with someone as a client of your service. Case notes can also be referred to as consultation records. Your code of ethics, your insurers, and the law all insist you have and keep them, usually for six or seven years.
Typically case notes will be comprised of:
- The contract (agreement to boundaries and responsibilities)
- The intake (questions and answers)
- The session notes (process and/or progress)
When necessary, case notes must also include:
- Any additions, extensions or alterations to the contract (eg adding more appointments, the decision to curtail and refer, etc)
- Extra permissions as named in the Code of Ethics
- Any resulting communications with a permitted third party
How to Store Case Notes
Case notes can be divided into two types of data:
- Personal data, also known as non-sensitive personal data.
- Sensitive data, also known as ‘special category data.
Although we think of the data involved as generally written or typed, the information may be recorded by any means – audio, video etc.
Both have to be processed differently.
Sensitive or special category data includes information such as a person’s race, ethnic origin, sexual orientation, genetic or biometric data, mental health, sexual health, political beliefs, trade union membership. We can only record sensitive information with the client’s explicit consent unless it is something they have already made public.
Personal data is generally any piece of information that may be used to identify someone; name and surname, home address, email, location, IP address. Date of birth, place of birth and gender are considered non-sensitive.
It is important to store the two types of information separately so that personal data cannot be used to put an identity to the sensitive data. For us this means:
- Keeping sensitive data out of the contract document
- Keeping identifiers such as names off the session notes
- Deciding whether to have a single intake form or two and whether the information contained gets filed with the contract or the session notes, to keep personal and sensitive data separate. This will depend on the depth of your necessary intake questions.
The next four pages address these documents in turn.
Author: Cheryl White, EFT Test Manager