Recordkeeping Procedures- Maintenance and Disclosure of Records, Part One

Hi. Welcome to part twenty-two of the Supervised Visitation Monitor Training, brought to you by Family & Children’s Counseling Services, Inc. You can find us online at www.HealPlayLove.org.

In this segment, we will learn about the Role and Responsibilities of the Supervised Visitation Monitor- specifically, maintenance and disclosure of records.

Section j of Standard 5.20 reads…

(j) Maintenance and disclosure of records for professional providers

(1)Professional providers must keep a record for each case, including the following:

(A)A written record of each contact and visit;

(B)Who attended the visit;

(C)Any failure to comply with the terms and conditions of the visitation; and

(D)Any incidence of abuse as required by law.

Take a look at your Contact Log from your Training Manual. You can print one and keep it in each client’s file and jot down the date, time and description of contact along with your signature, or you can do a ‘file, save as’ for each new case and use an electronic signature.

(2)Case recordings should be limited to facts, observations, and direct statements made by the parties, not personal conclusions, suggestions, or opinions of the provider. All contacts by the provider in person, in writing, or by telephone with either party, the children, the court, attorneys, mental health professionals, and referring agencies should be documented in the case file. All entries should be dated and signed by the person recording the entry.

Take a look at the Sample Note One from your Training Manual. Circle all the words or phrases that could be considered opinions, judgements, interpretations or conclusions. Pause this video to complete this assignment.

Now, take a look at Sample Note Two from your Training Manual. This is the same note, only without the opinions, judgements, interpretations or conclusions.  Pause this video and find the differences in the two notes.

Can you see the difference in using opinions vs. factual statements?

Let’s go back to Standard 5.20…

(3)If ordered by the court or requested by either party or the attorney for either party or the attorney for the child, a report about the supervised visit must be produced. These reports should include facts, observations, and direct statements and not opinions or recommendations regarding future visitation. The original report must be sent to the court if so ordered, or to the requesting party or attorney, and copies should be sent to all parties, their attorneys, and the attorney for the child.

(4)Any identifying information about the parties and the child, including addresses, telephone numbers, places of employment, and schools, is confidential, should not be disclosed, and should be deleted from documents before releasing them to any court, attorney, attorney for the child, party, mediator, evaluator, mental health professional, social worker, or referring agency, except as required in reporting suspected child abuse.

Thank you for watching. I’ll see you again at the next video, Recordkeeping Procedures, Part Two.

Family & Children’s Counseling Services, Inc. is a California LMFT Corporation owned and directed by Melinda Haynes, MA, LMFT 102308. 

You can find FCCS online at www.HealPlayLove.org.

You can find Melinda’s therapy channel, Can We Talk?, at https://www.youtube.com/canwetalk