Educational Case Management service providers will use their professional skills and experience to decide on what actions they should take in each situation of potential harm. Where possible, decisions should be discussed with the Practice Manager or colleague.
Duty of care is breached by failing to do what is ‘reasonable’ or by doing something unreasonable that results in harm, loss or injury to another.
Educational Case Management service providers will inform clients and their parents/carers/support persons of potential risks with the aim of an ‘informed decision’ reducing potential risk.
Educational Case Management Practice Manager and /or service providers will address:
- the level of risk and likelihood of harm
- the type of risk: sexual, emotional, physical.
- informed decisions/actions that may minimise the risk of harm
- professional standards that may apply
- discrimination and overly restrictive options
- compromises – rights of others
- assessment of potential ‘risk of harm to themselves and to others
- the need to safeguard others from potential harm
- confidentiality
- the service proposed and that this service is consistent with the policies and procedures outlined in this manual.
- service providers that do not have the expertise to manage potential ‘risks’
- concerns reported by service providers regarding the safety of clients and their families.
- Client’s capacity to make their own decisions regarding potential ‘risk’. This may require the support of family, carers, support persons, on an informal basis or more formally through case planning with other professionals (e.g. GP, Newcastle Mental Health team).
- The management of aggressive or threatening clients who may attend the practice
- their own safety and the safety of others over an aggressive client
Privacy and confidentiality of information
The client’s rights for privacy, confidentiality and access to information should be respected in relation to service provided and case notes recorded. The client’s rights to privacy and confidentiality also need to be respected.
Privacy
Educational Case Management service providers will:
- Recognise the need for client privacy (and family) ensuring discussion to be always held within consultation rooms and NOT waiting room.
Plan team meetings in the home only when it suits the client and their family/carers etc - Seek only the pertinent history required for developing appropriate therapy and intervention.
- Respect confidentiality.
Confidentiality and access to information
The client’s confidential information is collected as part of the new referral process and initial consultation by the Practice Manager. This information will NOT be released to any third party unless it is with the consent of the client (guardian if under the age of 18 years). Information regarding the client can only be released to other Allied Health professionals and those in the medical profession, professionals who may require the information as part of their role in caring for the client’s well-being. Additionally, any private information must be released to the client at his/her request as in accordance with the Freedom of Information Act, 1982.
Educational Case Managers will ensure that:
- Client files on power diary and hard copy are maintained with appropriate security usernames with hard copies kept in locked filing cabinets. Keys are kept by the Practise Manager
- Client case notes recorded on the computer-shared drive are protected by username and password on-site cloud security
- All clients have access to their records and are informed of this right.
Professionals Code of Ethics and Code of Conduct
Refer to professional domain
Client records
Client’s file notes are a summary of clinical observations, discussions with parents/carers/support persons, therapy, interventions, and interactions between the service provider and the client.
Recording these interactions that take place during each consultation is a key part of providing quality therapy -goals and ensuring there is a client-centred therapy focus.
Client files include:
- Individual hard copy file: red (NDIS), blue (speech), and yellow (psych) stored in lockable filing cabinets
- Power diary file with case notes and uploaded evidence, referrals, medical reports, and assessment results- username and password protected
- Hard copy file will contain referral form, copies of complaint forms, reports/information from other agencies, NDIS access request application, school reports, standardized assessment proformas.
- Case notes are made immediately after the contact with the Client (usually in the last 5-10 min of the consultation period) or as soon as possible but certainly not more than 24 hours after the consultation.
- If an error is made with the content of the case notes- already uploaded onto the power diary, there is no means to rectify it.
- Service providers who have made an incorrect notation need to create another case note file explaining the incorrect information provided in previous locked case notes.
- Case notes to be entered-into power diary in a factual objective manner respecting the client’s feelings and dignity. Clinical judgements need to be noted accordingly.
- No case notes are to be stored in hard copy files
- No files are to be removed from the premises.
- Access to files from a home office is via security username and passwords
- Team viewer (allowing access to the desktop of practice computer from home office) required security usernames and passwords
- Assessment results are uploaded and statistically calculated via Global Interactive -Pearson Clinical website- requiring security username and password
- All files are stored in the filing cabinet when not in use. When files are placed in pigeon holes this indicates immediate ‘attention’ required resulting in the file being removed within 60 mins and attended to by the service provider.
- Client files to de returned to the filing cabinet are filed immediately after each session by the service provider or if time does not permit placed in the ‘to be filed’ tray and filed by the administration assistant within a 60-minute time frame.
- Files are NOT to be left unattended on desks or in pigeon holes of service providers where other people have access.
- Files sent by registered mail only when subpoenaed.
- Keys to the filing cabinet holding client records will be held by the Practice Manager.
Every 6 months (June and December) a random file audit is undertaken by the Administrative assistant. Under the supervision of the Practice Manager, certain files are ‘culled’ due to ‘non-attendance. These client files are filed in an archive filing system located in the kitchen for a period of 7 years. Clients that have not attended the practice for a period of 6 months will result in a letter written to the GP and/or medical profession indicating no contact with the client. This letter will highlight to the medical professional that ‘closure’ and/or ‘completion of therapy’ did not occur. The file audit will be managed by the Practice Manager to ensure:
- objective and non-judgmental decisions are made re-reconnecting with the client
- the decision in closing the file is based on professional judgement and assessment
- the decision is consistent with organisational and legislative requirements
- all letters are dated and signed by the Practice Manager.
Dealing with suspected abuse- protocol for Service Providers
Service Providers at Educational Case Management are ‘Mandatory’ reporters of abuse and will determine the level of ‘risk’ based on clinical judgement and information provided.
- Abuse: (physical, sexual, emotional, and neglect)
- Any evidence of physical abuse will be reported by service providers.
- Any evidence of neglect whilst in the care of another who fails to provide conditions that are essential for the health and well-being of that client will be reported.
- Any evidence of sexual abuse will be reported
- Any evidence of psychological abuse which is likely to have an adverse impact on the client’s emotional well-being will be reported.
- Any evidence of domestic violence which has the potential to harm the client will be reported.
- Service Providers will respond to ALL confirmed or suspected abuse of clients
- Service Providers understand their client’s well-being takes precedence over those of the victim’s family or of other members of the community.
- The intervention will prioritize ‘safety’ and ongoing protection from violence and abuse.
- Clients will be encouraged to make their own decisions where appropriate. The clients will be provided with information and an opportunity to discuss all relevant options, including the option to refuse services. Service Providers will adhere to mandatory reporting guidelines.
- Criminal offences will be dealt with accordingly- including reporting to the police when appropriate.
- Confidentiality of information is respected in accordance with the service provider’s professional ethics, agency policy and legal obligations.
- The desire of a person for an independent advocate of their own choice will be respected.
- All suspected cases of abuse must be reported to the Practice Manager or colleague.
Mandatory Reporting-Child protection
- Service Providers are mandatory reporters.
- Service Providers are professionally responsible as clinicians to respond appropriately if a child or adult tells them of abuse
- Service Providers are required to report to the Department of Community Services (DoCS) if they suspect a child under 18 years has been abused or is at risk of being abused.
- Service Providers are responsible for taking the specific steps in making a report to the Department of Community Services
- Service Providers must provide information in relation to a child protection matter to the Department of Community Services when requested by the Department to do so
- Service Providers can seek feedback from the Department of Community Services about the report
- Service Providers must know where to get support if they need it because dealing with child abuse is sometimes complex and can be stressful- consult colleague, supervisor, Practice Manager.
Client Complaints
Client Records-security storage facilities
To access the Power Diary system users -service providers and administrative staff must enter their unique username and password details into the login page. The usernames and passwords for each user have been created under Educational Case Management Account. This information is NOT to be given to another person. The login and authorization of each user are processed over a secure and encrypted connection. The Practice Manager limits what each service providers and administrative staff member can access within the account. The Practice Manager can change at any time the service providers and administrative staff member security settings, including suspending or removing their access altogether. This will take immediate effect, even if they are currently logged in.
Activity Recording:
User activity within your Power Diary account is recorded. All service providers and administrative staff members can see when a user logged in (including their computer’s IP address) and exactly what they viewed and changed in your Power Diary Account. The Practice Manager has a range of filter options that allows her to search and view specific information such as which service providers and administration staff have accessed a client file, or have made or changed appointments etc. The system stores the past two months of activity.
Data Transmission, Storage and Backup
The servers are located in a secure, state-of-the-art data centre in Sydney, Australia and are protected by a firewall with redundant power & cooling systems. The data is backed up every 10 minutes and an additional offsite backup is made at 1am every night to a geographically separate secure data storage facility. The connection between the browser and the servers is protected so that information transferred is encrypted using SSL technology. This prevents others from intercepting and reading this information during transit. If Educational Case Management PL should at any stage decide to discontinue use of Power Diary, the removal of all information related to this account from the Power Diary system is removed. This will be completed within seven days of a request.
Maximizing Security
Whilst Power Diary have in place significant measures to protect and maintain the safety and security of the data collected by Educational Case Management PL, no system, whether electronic or otherwise can ever claim to be absolutely secure. Power Diary relies on service providers and administration staff keeping ALL login details confidential. Service providers and administration staff MUST NEVER give Power Diary login information to anyone (refer to Appendix 5: Security Indicators)
