Records Management and Review- Jerry Shih PHD

Jerry Shih PHD

1. Management and Review
of Client Records
at a University Counseling Center
Jerry Shih, Ph.D. L.P.

2. General Case Note Process
•Notes are entered in Titanium client file
within 48 hours (preferably same day).
•Paper documents are scanned into
Titanium client file.
•Supervisors sign off on trainee notes.
•Director or Clinical Director must approve
any changes after a note is locked.

3. Philosophy
•Writing case notes is a complex task; counselors
grapple with opposing concerns.
•There is no single, systematic “cookbook”
approach.
•Each counselor must strive to find a balance in
writing concise, behaviorally-focused, non-
labeling case notes that are useful and
adequately document the counseling process.
•The audience may include the client, other
Counseling Center staff, other mental health
professionals, legal professionals.

4. Case Note Guidelines
•Focus primarily on client behavior.
•Be tactful and objective.
•Be concise. Avoid excessive detail unless
documenting a crucial interaction.
•Avoid value-laden judgments.
•Avoid recording hearsay as facts.
•DSM diagnoses are not generally charted.
Senior staff may chart DSM diagnoses if
clinically warranted. Trainees should consult with
supervisors first.

5. Case Note Guidelines (cont.)
•Record all pertinent data even if you think
someone may object to it; do not let sensitivity to
someone else’s perspective overcome your
professional discretion regarding important case
information.
•Do not use symbols, shorthand, or
abbreviations, except to indicate tests, e.g.
MMPI-2. Spell out numerical quantities.
•Use complete sentences and proper
punctuation.

6. Forms
•Initial Interview
•Counseling Plan completed by end of third
session
•Extension Request (for more than 15
sessions)
•Closing Summary (if seen more than 2
sessions)

7. Record Review Process
•Supervisors review timeliness and content of
trainee case notes.
•Weekly: Clinical director checks senior staff’s
Titanium task lists to ensure timeliness of
documentation.
•Bi-weekly: Clinical director spot checks senior
staff case notes to ensure adherence to
documentation guidelines.

8. Record Review Process (cont.)
•Monthly: Clinical director ensures that all clients
seen 3 or more times have Counseling Plans.
•Case Review Committee processes Extension
Requests submitted since last meeting.
•Quarterly: Clinical director ensures that all
clients seen 15 or more times have an approved
Extension Request.
•End of semester: Clinical director ensures that
there are Closing Summaries for clients after 45
days of no contact.