Each contact you have with the client, whether it is by telephone, email or in person, must be recorded with the date, name of the individuals involved, information shared and plan of action for the future. I have developed a form with four sections:
1. How the person made contact
2. Billing information (date, name of individual, time used during the contact, rate per hour, total fee for the contact, organization or person responsible for fees).
3. Blank lines where I can write details of the contact. Make such that you writing and sentence structure are so clear that a child could read what you wrote and understand it.
4. Action steps for dealing with this (file, request file extension, return call, provide referral)
All information, reports and notes must be put into a file that is labeled for that particular client and stored in a locked cabinet and secure setting.
When the contact consists of billable time, I immediately invoice the appropriate source, print the invoice and file it on the left-hand side of the file. I also record the invoice on a summary sheet which I keep at the top of that side of the file.
When reports are received from other professionals or organizations, I file them on the right-hand side of the file under a colored sheet of paper that separates them from my file notes which are filed chronologically on top of them. All information from other sources is confidential and should not be shared with the client or with other sources without the written permission of the individual who prepared the report.
When services have been completed and the balance of the account has been paid in full, remove the file from the active drawer and use a file closure summary sheet to capture your involvement. This should include the names, file numbers, reason for closure, number of sessions, reason and source of original referral, special comments and a signature. This form is secured on the right-hand side of the file which is then moved to the filing cabinet that houses inactive files. Remember to also to move the customer file in your computer bookkeeping system to inactive status.
Never release any information from the file to anyone unless you have written informed consent from the client or a legal subpoena. In either case, consulting with a practice adviser or your regulatory body will likely be helpful in determining what and how to release information. Also, never leave a file in any place where it might be seen by others. Even if a person only reads the file label, this is a confidentiality breach.
It is also best to not remove files from your office to ensure that they will not be misplaced or lost.