C. Documentation
- Barry Smith
9.9 File Documentation
Vocational rehabilitation professionals must establish and maintain accurate, timely, and sufficient documentation that reflects the services provided. This documentation should identify who provided the service.
If case notes need to be altered, the original note must be preserved, with details on the date, who made the change, and the reason for the change.
Key documentation includes:
Reason for referral
Professional disclosure/informed consent
Signed consents for information release
Initial vocational assessment
Correspondence
Regulatory orders
Written evaluations
Vocational assessment/testing results
Agreements (e.g., training-on-the-job)
Medical/psychological reports
Other interventions
Written closure report
Legal Considerations:
Documentation is considered a legal record and must be factual and objective.
Reporting requirements may vary based on the referral source and jurisdiction, so professionals must comply with those requirements.
Key information to be maintained includes:
Written evaluation, plan, and closure report
Medical/psychological reports with current work restrictions
Correspondence between parties
Regulatory orders
Updated authorization for information requests/releases
Confidentiality and Record Storage:
Client records are confidential and cannot be disclosed without client authorization or legal requirements.
Appropriate storage mechanisms should be in place to protect the information.
Records should be maintained according to jurisdictional requirements or agency policy, and if destroyed, it must be done confidentially.
9.10 Meeting Documentation
VR professionals often attend meetings with clients, employers, insurers, and other parties. It is essential to keep accurate and objective records of these meetings.
If meetings are electronically recorded, all participants must be informed beforehand and agree to the recording.
Quiz:
What should be included in the file documentation for vocational rehabilitation professionals?
a) Only the reason for referral and medical reports
b) The reason for referral, signed consents, assessments, and written reports
c) Just the client’s medical reports
d) Only the final closure report
If a case note is altered, what must be included?
a) The original note must be deleted
b) The altered note must include the date, the person who made the change, and the reason for the change
c) The original note remains unchanged, and no additional information is required
d) Only the reason for the change must be included
Why is documentation in vocational rehabilitation considered a legal record?
a) It contains confidential medical information
b) It may be used in legal proceedings and must be factual and objective
c) It is only used for internal agency purposes
d) It is not legally significant
What type of information should always be maintained in the client file?
a) Only the written evaluation
b) Written evaluation, plan, closure report, and other relevant documents like medical reports
c) Only the medical reports and closure report
d) Just the closure report
What is required when a vocational rehabilitation professional records a meeting electronically?
a) No one needs to be informed about the recording
b) The recording must be kept secret from the participants
c) All participants must be informed beforehand and agree to the recording
d) Only the client must be informed of the recording
How should vocational rehabilitation professionals handle client records after the client’s case is closed?
a) They should be destroyed immediately
b) They should be retained based on jurisdictional requirements or agency policy
c) They should be shared with other agencies for further use
d) They should be stored indefinitely without consideration of legal requirements
What is the general rule for maintaining client confidentiality?
a) Client records can be shared freely among professionals
b) Client records can be disclosed only with client authorization or legal requirements
c) Records are not confidential in vocational rehabilitation
d) Client records can be disclosed only with the client’s verbal consent
What must be done if records need to be destroyed?
a) Records can be destroyed without any precautions
b) Records should be destroyed in a manner that preserves confidentiality
c) Records should be discarded without any formal process
d) Only the written evaluation needs to be destroyed
Answer Key:
b) The reason for referral, signed consents, assessments, and written reports
b) The altered note must include the date, the person who made the change, and the reason for the change
b) It may be used in legal proceedings and must be factual and objective
b) Written evaluation, plan, closure report, and other relevant documents like medical reports
c) All participants must be informed beforehand and agree to the recording
b) They should be retained based on jurisdictional requirements or agency policy
b) Client records can be disclosed only with client authorization or legal requirements
b) Records should be destroyed in a manner that preserves confidentiality