2022 Edition

Program Administration (CA-PRG) 1: Case Records

Case records contain sufficient, accurate information to:
  1. identify the individual or family being served;
  2. support decisions about interventions or services; and
  3. document the delivery of services.
NA The organization provides only Early Childhood Education (ECE) and/or Out-of-School Time Services (OST).
 
NA The organization provides only non-clinical group, crisis intervention, and/or information and referral services.

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Purpose

Service delivery practices guide the administration of safe, effective programs that respect personal dignity and self-determination.
Related Standards:
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the PRG 1 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the PRG 1 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the PRG 1 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the PRG 1 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Case record content and maintenance procedures
  • Mock case record, table of contents, or case record outline for each service
  • Review case records
  • Interviews may include:
    1. Program directors
    2. Relevant Personnel

 
Fundamental Practice

CA-PRG 1.01

The organization maintains a case record for each individual or family.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 1.02

Case records contain information necessary to provide services including:
  1. demographic and contact information;
  2. the reason for requesting or being referred for services;
  3. up-to-date assessments;
  4. the service plan including mutually developed goals and objectives;
  5. copies of all signed consent forms;
  6. a description of services provided directly or by referral;
  7. routine documentation of ongoing services;
  8. documentation of routine supervisory review;
  9. discharge or aftercare plan;
  10. recommendations for ongoing and/or future service needs and assignment of aftercare or follow-up responsibility, if needed; and
  11. a closing summary entered within 30 days of termination of service.
Related Standards:

Interpretation

This standard describes the basic elements to be included in individual case records. COA recognizes that in some cases not all listed information is obtainable for an individual or family. In these cases, an explanation should be placed in the case record. Additionally, the listed information may not be routinely available due to the nature of the service, e.g., a low demand shelter or drop-in center.
 

Interpretation

Regarding element (h),"documentation of routine supervisory review" refers to the quarterly review of individual cases that is found in the Service Planning and Monitoring sections of most Service Standards. This review is unrelated to Supervision between the supervisor and personnel addressed in CA-TS 3.

Interpretation

Case records and signatures can be paper, electronic, or a combination of paper and electronic.

EAP

Interpretation

In Employee Assistance Programs, case records contain appropriate information to demonstrate the status of the case and whether it is open or closed.
 

FEC

Interpretation

 
Elements (h) and (i) are not applicable to credit counselling organizations.
 
DV

Interpretation

 
When domestic violence services are provided, documentation in case records should be limited to essential information. Personnel should be conscious of the language they choose, avoid unnecessary detail, and refrain from editorializing or recording opinions.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record content and maintenance procedures need strengthening; or
  • In all but a few cases, the organization complies with the standard; or
  • One of the elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • In a significant percentage of cases, the organization does not comply with the standard; or
  • Two of the required elements are not fully addressed; or
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Three or more of the required elements are not fully addressed, or
  • Two or more elements are not addressed at all.

 
Fundamental Practice

CA-PRG 1.03

The case record contains essential medical and legal information including, as applicable:
  1. orders for and results of psychological, medical, toxicological, diagnostic, or other evaluations;
  2. documentation of all prescribed and over-the-counter medications including copies of all written orders for medications or special treatment procedures, when applicable;
  3. special treatment procedures, allergies, or adverse treatment responses; and
  4. court reports, documents of guardianship or legal custody, birth or marriage certificates, and any legal, regulatory, and/or contractual directives related to the service being provided.
NA The organization does not obtain legal or medical information.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record content and maintenance procedures need strengthening; or
  • With a few exceptions records contain necessary and required information.
3
Practice requires significant improvement; e.g.,
  • Procedures require significant strengthening; or
  • Many records do not have the necessary or required information; or
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Two or more elements are not addressed at all.

 
Fundamental Practice

CA-PRG 1.04

Case record entries are made by authorized personnel only, and are:
  1. specific, factual, relevant, and legible;
  2. kept up to date from intake through case closing;
  3. completed, signed, and dated by the person who provided the service; and
  4. signed and dated by supervisors, where appropriate.
Examples: When selecting an electronic record keeping system, the organization may consider, among other things, whether or not the system has the capacity to:
  1. verify the individual’s identity and ensure that each electronic signature is unique to the individual; and
  2. ensure that the signature will remain tied or connected to the content being signed for as long as the record is maintained.
 
Examples of ways to verify the authenticity of digital signatures when using electronic records include, but are not limited to: a digitalized signature via tablet or two identifying components such as a user identification code (ID) and password/personal identification number (PIN). 
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record content and maintenance procedures need strengthening; or
  • In a substantial percentage of cases reviewed, the organization complies with the standard; or
  • One of the elements is not fully addressed. 
3
Practice requires significant improvement; e.g.,
  • In a significant percentage of cases, the organization does not comply with the standard; or
  • Two of the required elements are not fully addressed; or 
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Three or more of the required elements are not fully addressed; or 
  • Two or more elements are not addressed at all. 

 
Fundamental Practice

CA-PRG 1.05

Progress notes comply with legal, regulatory and/or contractual requirements and are entered:
  1. at least quarterly; or
  2. monthly for individuals receiving protective services, out-of-home care, day treatment, or frequent or intensive counseling or treatment.
Related Standards:
FEC

Interpretation

For credit counselling organizations providing DMPs, disbursement records can suffice as evidence of progress made.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record content and maintenance procedures need strengthening; or
  • Progress notes in most case records are up to date and reflect the progress of the client; or
  • One of the elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • In a significant percentage of cases progress notes have not been kept up to date; or
  • In a significant percentage of cases progress notes are lacking in content and do not reflect the progress of the client; or
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-PRG 1.06

At case closing, case records are reviewed and unsummarized notes, personal observations, and impressions are expunged unless otherwise required by law, regulations, and/or contracts.
NA The organization only provides Financial Education and Counselling (CA-FEC) services.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Most case records are reviewed prior to closure and unnecessary information is removed.
3
Practice requires significant improvement; e.g.,
  • Many closed records contain worker notes and/or unnecessary material.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-PRG 1.07

Unless otherwise mandated by law, the organization maintains case records as follows:
  1. for at least seven years after case closing for adults;
  2. until the age of majority or seven years after case closing, whichever is longer, for minors; and
  3. disposes of case records in a manner that protects privacy and confidentiality in the event of the organization's dissolution.
Related Standards:
FEC

Interpretation

Credit counselling organizations are required to maintain case records for a minimum of one year unless otherwise mandated by law.
Examples: Proper disposal of paper and electronic records can include, but is not limited to, shredding paper records, clearing electronic files when computers are replaced or reassigned, and destroying electronic media such as flash drives.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the elements needs strengthening; or
  • With few exceptions procedures are understood by staff and are being used.
3
Practice requires significant improvement; e.g.,
  • One of the elements has not been addressed at all; or
  • Procedures are not well-understood or used appropriately.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.