1. Scope

1.1. The purpose of this procedure is to outline the collection and management of client information.

2. Background

2.1. Client records are kept:

  • as a history of contact with the client.
  • for continuity of care.
  • to evaluate a client’s progress and health outcomes over time.
  • for professional and legal accountability.
  • to communicate safety planning.
  • to articulate case formulation.
  • as a record of evidence-based treatment.
  • for report writing (where reports are legally requested and authority has been given).

3. Client Records

3.1. Open Arms staff are bound by the Department of Veterans’ Affairs (DVA) Records Management Policy, which provides high-level direction to all staff on the handling of all records of business activities, including counselling, and identifies roles and responsibilities of workers and supervisors. The policy is supplemented by the Secretary’s Instruction – Recordkeeping within DVA, which links recordkeeping to the principles of the Public Governance, Performance and Accountability Act 2013 (PGPA) for efficient, effective and ethical use of Commonwealth resources.

3.2. Regional Directors are responsible for ensuring that their staff keep and securely store full and proper records in accordance with section 37(2) of PGPA. Electronic record data is accessible only by Open Arms staff on a need-to-know basis. All Open Arms staff are responsible for ensuring timely and accurate entry of data into the Open Arms Client Management System, referred to as Veterans’ Electronic Records Application (VERA), and overseen by Regional Leadership Teams.

3.3. Open Arms workers are required to mark attendance and record clinical notes in VERA on the same day as a contact. Other new information related to a client must also be entered into VERA on the day of its receipt. Session summaries must:

  • record the date, time and duration of the session or other contact.
  • state whether the session or other contact is face-to-face, telephone or a home visit.
  • include the names of those present at the session.
  • be a discrete record for each session or other contact.
  • be numbered (with session number or page) and stored sequentially.

3.4. Client records are kept as electronic records (although a paper record may be kept where it is considered necessary by the Regional Leadership Team; see below).

3.5. Electronic storage of client records must be in accordance with DVA ICT Security Policy.

3.6. Three main types of client records are maintained by Open Arms:

3.6.1. Individual records that are created at the time a case is registered (cases are created for clients who access centre-based or outreach Open Arms services (a minimal individual record is created for mental health training workshops).

3.6.2. Group program records that are created at the time a group is confirmed and contain no individual information.

3.6.3. Contact records, where a contact does not lead to allocation to a service. The outcome is entered into the VERA record as a contact, and the information can be retrieved if a client makes further contact at another time.

4. Client Information from External Sources

4.1. Client information received from external sources, including referrals, reports and other documents, may only be collected or used by Open Arms with client consent.

5. Paper Files and Storage Requirements

5.1. No Open Arms client records are registered on DVA records management systems.

5.2. Client information collected in hard copy with client consent, for example paper records such as handwritten session notes, medical reports and legal documents, are to be scanned and stored on VERA. In most cases, the original paper record need not be kept and may be destroyed via secure destruction (shredding or secure paper bins). Otherwise, it should be kept in a paper file as a record under the relevant client and a note of this made in the client’s VERA record.

5.3. A paper record is created whenever a handwritten note is created in relation to a client, or a document is received in hard copy from a client (or another service provider, see 4.1 above) with no electronic copy. Where possible, a paper record can be scanned into VERA and then the paper original can be destroyed. However, where retention of a paper record is necessary, a paper file may be created for a client and a note to this effect placed in the client’s VERA record.

6. Single record

6.1. Each client will have one record in VERA (an Individual Profile). A record of each different service provided to this client will be kept as a separate Case File within the Individual Profile, with Service Files within the Case File.

7. Content of a Client Record

7.1. Client record notes must be:

  • brief, relevant, legible and easily understood (avoiding or explaining jargon, acronyms and abbreviations).
  • objective, stating reasoning and sources of information.

7.2. As a matter of good practice, session notes should record changes in the client’s condition between sessions, the client’s response to the previous session, reassessment of the client’s risk status, new agreed actions or plan for the next session, and the date of the next scheduled appointment.

7.3. A client file includes (as relevant):

  • the client’s full name (first name and family name) and title where relevant
  • intake information
  • screening tool results
  • client-informed consent for Open Arms to provide services
  • client consent to contact other supporters/providers and/or exchange relevant information
  • initial assessment (refer to the Open Arms Practice Standards for Assessment and Treatment of Clients for a comprehensive description) including a risk assessment
  • care plans including case formulations and safety plans
  • case reviews
  • specialist assessments
  • correspondence with the client
  • file notes for all sessions, including telephone and video sessions
  • a record of all other substantive interactions with the client or the client’s support or treatment network, including telephone calls, correspondence, clinical decisions relating to the client, and decisions/actions relating to risk
  • a summary at case closure including an exit plan.

7.4. The client record should not contain communications that are not directly relevant to that client. Such exchanges must occur outside any system that creates a record in the client’s file.

8. Storage of Disturbing or Graphic Content

8.1. Photos of a distressing or disturbing nature sent from a client are an important part of a clinical record and must be appropriately stored. To limit exposure of the content to others, the images should be uploaded to VERA as soon as possible by the clinician who received the content.

8.2. Steps in VERA:

8.2.1. In the alert section of the client profile, insert the following words:

  • WARNING: On (insert date) graphic photographic content related to self-harm (or other) was placed as an attachment in the Service File (insert ID number). As this material is potentially distressing, care should be taken if/when there is a clinical or legal need to access it.

8.2.2. Content should be stored as an attachment within the current Active Service File and stored within the attachments tab labelled “graphic photographic client material”. The clinician should enter a service event where details should be stored including what content was received, how it was received, where it is located and what clinical action was undertaken.

8.2.3. Once uploaded to VERA, the content is to be deleted off the device it was sent to/from and any other copies deleted.

9. Destruction of Electronic and Paper Records

9.1. Destruction of both electronic and paper records must accord with the requirements of the Archives Act 1983 (Archives Act) and the Repatriation Commission Records Disposal Authority 2007. National Office staff and Regional Leadership Teams collaborate to conduct regular file audits to evaluate and monitor the extent to which file management policies and procedures are complied with.

9.2. The DVA Secretary has directed that records destruction may only take place with the approval of the Director of Records and Information Management and the disposal of DVA records is managed by the Records and Information Management Section. However, a copy of a hardcopy (for example, handwritten) record scanned into VERA, represents a record and the hardcopy can be destroyed (see Section 5 of this procedure).

9.3. All paper records associated with an Open Arms client (in-centre or outreach) including all handwritten session notes, file notes and emails, are Commonwealth property and cannot be destroyed without making an electronic version by scanning well-structured, legible clinical notes or transcribing rough notes.

9.4. Paper records that are scanned and stored in VERA may be destroyed provided that the reproduction is functionally equivalent to the source record, and the record:

  • belongs to Open Arms.
  • does not have ‘intrinsic value’.
  • is not required to be kept in its original form by legislation.
  • is not required as part of a current or likely judicial proceeding.
  • is not subject to a current application for access under the Freedom of Information Act 1982 (FOI Act) or other legislation.

9.5. Outreach counsellors may not dispose of or destroy an Open Arms client record (including handwritten notes), but must deliver them to the relevant Open Arms office or upload them to VERA. Once an electronic version of a record is created and saved to VERA, the paper record can be lawfully destroyed. Upon consent from Open Arms to dispose of a paper record, Outreach counsellors must use secure destruction. If there is no means of secure destruction available, the records should be delivered to the nearest Open Arms office.

9.6. All outreach counsellors’ paper client records should be scanned and uploaded into VERA at the time that services occur. Where an outreach counsellor ceases to provide Open Arms services, all paper records for Open Arms clients must be scanned and uploaded to VERA, or the paper records transferred to the nearest Open Arms office by registered mail or hand delivery.

10. Access to VERA

10.1. Only users with a legitimate business need have access to VERA. Each user is given the appropriate level of access to data as determined by their login identification code.

11. File Audits

11.1. Audits of VERA client files are conducted nationally in accordance with the VERA Client Record Audit Instruction.

12. Security of Records

12.1. Open Arms records are separate Departmental records and access is restricted to Open Arms staff (including outreach counsellors) on a business needs basis.

12.2. Although there is no legal impediment to DVA access to Open Arms files, there is a long-standing Ministerial commitment to the ex-service community, that Open Arms client files remain separate from files maintained by DVA, and that client information can only be released to the Department with the client’s consent. Open Arms’ client records may also be provided to DVA in order for DVA to assist with various administrative tasks, for example, managing FOI requests and assisting with privacy investigations.

12.3. Client information in electronic form (VERA) is password protected. Any physical client records are kept in a locked Class C cabinet or are archived in accordance with the Archives Act and Departmental Records Management Policy. Locked cabinets are kept in a locked storage room.

13. File Archiving

13.1. Open Arms client records are covered by the National Archives of Australia Records Authority entry 16393. Under this authority, disposal of client records documenting counselling and guidance services provided to veterans or their dependents or ex-partners is not authorised; although records documenting debriefing reports produced at the completion of a series of group counselling sessions can be destroyed seven years after the last action.

13.2. Any action regarding an Open Arms record is also dependent upon any National Archives of Australia (NAA) directives on non-disposal of records. Two currently operate:

  • Vietnam veterans’ files are subject to special retention provisions for future research purposes under the Archives Act. There is a records disposal freeze on all records relating to the service in Vietnam of servicemen and public servants.
  • A freeze on disposal of Commonwealth records potentially related to allegations, handling and consequences of sexual and other forms of abuse in the Defence organisation is in force until otherwise informed by the National Archives.

13.3. Archive actions (archiving or retrieval) are the responsibility of the Regional Clinical Practice Manager. Deposit or retrieval of records are initiated by contacting the DVA Records Services team.

13.4. Open Arms will archive a client’s paper record 12 months after the client’s death or if the client has not accessed counselling for five years, where:

  • the client did not have a joint file (for example, a father and son), and
  • the paper record cannot be scanned and uploaded to VERA.

13.5. Group program records that do not contain any client information (noting that any client information should be kept in the client’s individual record) may be archived after two years from the time the group program took place.

13.6. Archived records can be accessed within 24 hours of request by each region’s designated records person. Archiving actions are recorded in VERA.

13.7. Legacy electronic records (created prior to July 2013) are kept in the Veterans Management Information System (VMIS) and are protected by data security. Although supported by secure DVA ICT and paper-based record management systems, VMIS is managed within Open Arms and individual client records remain the property of Open Arms.

14. Secure Transportation of Client Paper Records

14.1. Client paper records are not removed from the Open Arms office for day-to-day purposes, including outreach visits, working from a satellite or other client work outside the office. For these purposes, the client’s record in VERA should be accessed by a laptop or tablet device.

14.2. When a client re-locates, and services are expected to continue, their information in VERA is available nationally. Any paper record is forwarded to the appropriate Open Arms office. Written consent from the client is preferred but not required for this to occur. Paper client records must be conveyed by DVA’s preferred provider, Decipher. For further instruction see: DVA Mail and Courier Procedures.

15. Records Management and Outreach Counsellors

15.1. Open Arms may only collect client information where it is reasonably necessary for, or directly related to, Open Arms functions or activities. This means outreach counsellors must be aware of Open Arms functions and activities and be able to relate any collection of client information to these functions and activities. For instance, an outreach counsellor may collect client information in order to provide mental health services to a client.

15.2. Outreach counsellors must store client records in secure locked cabinets and must not allow client information to be inadvertently disclosed (for example, by allowing telephone calls to or about clients to be overheard, or by allowing client information to visible to others).

15.3. Outreach counsellors must only view client information for the purposes of providing a mental health service, and not for other reasons. Outreach counsellors must seek advice from Open Arms before deciding to disclose any client information to anyone other than the client.

15.4. Open Arms client records are Commonwealth property and Open Arms has a legal right to require that outreach counsellors surrender files. This includes any notes (whether paper or electronic) produced by outreach counsellors in the course of providing a service to Open Arms clients.

16. Parent Policy

16.1. 101 Client Information, Rights and Records Policy

17. Subordinate Instructions and Templates

17.1. 101-01/ 01 VERA 4.0 Manual - Counselling
17.2. 101-01/ 02 VERA 4.0 Manual - Outreach
17.3. 101-01/ 03 VERA 4.0 Manual - Administration
17.4. 101-01/ 04 VERA Outreach Referral and Billing Guide

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