Section 3: Monitor and Document Support Activities

When providing support to a client according to their individualised plan, it is important that you monitor your own services to ensure the required standard of support is maintained.

You can monitor your own services by:

• continually reviewing your practices and making sure they align with the relevant service standards of the industry or organisation you work for
• regularly discussing with the client how support services are meeting their needs, and if there is any requirement for change
• monitoring the client’s progress towards their counselling plan to identify where specific interventions have or have not been effective in meeting client needs and goals
• liaising with other members of the client’s support team (with the client’s consent) to gather feedback about the services you provide
• discussing aspects of the individualised plan with your supervisor or the case manager for advice on how to improve your services or support activities.

Collaboration remains important in this part of service provision, and client feedback is important for determining whether your services are meeting their needs and identifying changes required. Collaboratively discussing progress and potential changes in an individualised plan not only contributes to a client’s sense of accountability but also serves to empower and enable the client.

As a counsellor, you will have opportunities to speak to your clients directly and ask them whether their individual needs or goals have changed, or whether the support activities they previously agreed to need to be reviewed and updated. With the client’s consent, it may be useful to involve a family member or carer who can support the client to express their feelings and revise their goals.

For instance, you may seek to involve the client in reflecting on the following questions:

• How are you finding the support you are currently receiving?
• Is the service meeting your needs?
• What would you like to be done differently?
• Is there anything that you would like more support with?
• Is there any aspect of your support that you are not comfortable with?
• Have your individual goals or needs changed?
• Have your personal circumstances changed?
• Do you have any specific interests you would like to pursue?
• How do you think the service could be improved?

How to write a reflective journal 

The presenter in this video provides insight into how to write a reflective journal for counselling. 

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The following case study demonstrates how a counsellor could monitor their own work to ensure the required standard of support is maintained.

Importantly, monitoring is not about finding fault in the services provided or condemning clients for not making desired progress. Instead, the aim is to make sure clients are truly benefiting from the support they receive, and for the continuous improvement of your practice.

Sometimes, changes may be required because of additional or unmet needs and practitioners may need to adjust the service plan to address these needs – like Ralph in the case study. However, it is also common to identify aspects of the plan that might need review because the client has since achieved greater independence or part of their initial goals, and they are prepared to reduce their reliance on support services in general.

For example, Ralph may report improvement in his relationships with others and now wants to look at building his self-esteem and take up some studies; he may even decide to reduce the frequency of counselling sessions or decide that counselling is no longer necessary. Essentially, individualised service planning is about tailoring services to meet the clients where they are at the time, in the most useful way possible.

How to use reflective journals to meet criteria

The presenter in this video discusses the importance of keeping a reflective journal and provides advice on how to use it to meet criteria. Answer the questions that follow. 

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Identifying and Reporting Signs of Additional or Unmet Needs

Many of your clients will have multiple needs which are complex and varied. When providing support to a client according to their individualised plan, you will need to observe any signs of additional or unmet needs and report this information to your supervisor or the relevant case manager.

Indicators that a client might have unmet needs include:

• The client verbally expresses things they would like to achieve that are not included in their individualised plan.
• Indications from family and/or carers that the client has other needs that are not being met.
• Signs of withdrawal, frustration, anger, or lack of interest in the counselling process.
• Signs of neglect within the client’s physical environment, physical appearance, or personal hygiene.
• Overdependence on alcohol or other substances.
• Behavioural changes, such as self-harm, negative self-talk, or relationship breakdowns.

Ways to respond will depend on the nature of the unmet needs. If those needs are beyond the service capacity of your service, your supervisor or the case manager may refer clients to other service providers who can more adequately address those needs. If the identified need is something that you or your organisation could assist with, such as supporting the client to develop life skills or coping mechanisms, the client’s needs should be re-assessed, and their individualised plan revised in collaboration with the client and their case manager.

Examples of client issues requiring urgent referral include:

• Child protection issues
• Suicide prevention/intervention
• Domestic and family violence
• Mental health issues
• Alcohol and other drugs (AOD) issues.

If the client requires a referral, you should notify the case manager and work with them to facilitate this referral. This might involve the case manager making the referral or them giving you authority to make it. If you are making a referral, you must ensure that you follow all of your organisational and confidentiality requirements.

Common referrals within the context of individualised support include:

• Accommodation services
• Child support services
• Crisis intervention services
• Culturally specific services
• Educational programs
• DFV services
• Financial services
• Legal services
• Living skills development programs
• Mediation services
• Mental health services
• Rehabilitation centres
• Specialist health services
• Statutory child protection authorities.

‘Warm referral’ is typically preferred when referring clients with complex needs. This refers to the counsellor or support worker facilitating the client to make contact with the referral agency, such as sitting with the client as they make the call or making a call on their behalf.

The following case study demonstrates how a counsellor identifies signs of additional or unmet needs of a client and appropriately refers the matter to the client’s case manager.

Identifying Aspects of The Individualised Plan That Need Review

An individualised plan must be continuously reviewed to ensure it reflects the current needs, preferences, and goals of the client. Refinement and adjustment over time are important and valuable features of individualised service planning/delivery. Plans are developed on the basis of assessment information and inevitably require modification as new information is introduced. For this reason, it is essential that both counsellor and client maintain flexibility in relation to goals, objectives and timeframes.

Monitoring needs to occur over the full course of the intervention. When progress is monitored, both counsellor and client are afforded the opportunity to share what they feel is working or not working in the individualised plan; what needs refinement or modification; what goals or objectives need to be removed, added, or altered and/or what timeframes need adjustment.

From your discussions with and observations of your client, you should be able to identify any aspects of the individualised plan that might need review and discuss the possibility of these changes with the client, your supervisor, or the case manager depending upon the required change.

Changes to the counselling plan that are within your skills, knowledge, and role as set out in the original individualised plan may only need to be discussed and agreed upon with the client. For instance, the client may decide to change fortnightly face-to-face appointments to a phone catch-up each month.

However, if you identify required changes to the plan that are beyond your skills/knowledge and work role, you will need to discuss the matter with your supervisor and case manager as appropriate. For instance, the client is planning to move to a different service catchment area, and they will not be eligible for accessing services from your organisation. It is your responsibility to notify your supervisor or organisation and make sure that the client is transitioned or referred to a suitable service provider in the new catchment area.

Changes that can impact the individualised plan may include:

• changes to the client’s health or abilities that impact their capacity to participate in agreed support activities, or broaden their opportunities for inclusion
• changes to the client’s lifestyle or living arrangements that impact their ability to participate in their community
• problems with the client’s ability to cope that may impact their capacity to work, study, or participate in social or community activities
• clients exercising their right to refuse to participate in activities outlined in the plan, which must be reported to a supervisor or case manager
• changes to the client’s personal interests or preferences that may encourage them to participate in a broader range of support activities.

Once changes have been made to the plan, you will then need to continue to assess whether the changes are effective or ineffective in helping the client achieve their individual goals. Your organisation will have policies and procedures in place for reporting and communicating changes to client needs and support requirements.

This may include attending a meeting with your supervisor or the relevant case manager, submitting a written report, or completing a standardised monitoring form. You should familiarise yourself with these guidelines to ensure you respond to your client’s needs promptly and appropriately.

The following case study demonstrates how a counsellor could identify aspects of the individualised plan that might need review.

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You should be well aware by now that a vital part of a counsellors’ responsibilities in providing individualised support is to complete relevant documentation and reporting requirements. When providing support to clients with complex needs, accurate and up-to-date documents from all collaborating services are essential for a comprehensive assessment of whether and how services are effective in meeting the clients’ needs, and whether there is any gap in support services.

As you have learned in CHCCSM005 - Develop, Facilitate and Review All Aspects of Case Management, case managers regularly assess clients’ needs and their experiences with services to make sure the arrangements put in place remain relevant and beneficial. Moreover, some documentation may be used to help external decision-makers (for example, Mental Health Tribunal, child protection agency) to review case progress and make further service decisions.

In addition, practitioners are often required to report informally and formally to their supervisor/manager, so as to make sure their practices (and any adaptations they are making for the clients) remain compliant with their organisational policies and protocols. The organisation also has a legal responsibility for maintaining client records for the number of years required and make sure they can be retrieved by the client or authorities for varying purposes.

As such, counsellors need to be aware of, and adhere to, legislative and organisational requirements about how documentation and reports are completed, maintained, and stored.

Maintaining Client Confidentiality and Privacy

It is critical that you maintain the confidentiality and privacy of your clients in all dealings, according to organisational policy and procedures. This means ensuring the client has access to their personal information and control over who else has access to it, and restricting individuals or organisations from using or disclosing information about a client that is outside the scope for which the information was collected.

The individualised plan will specify other individuals who are involved in the client’s case management team. Even though these people may already have knowledge of the client, you must still obtain the client’s consent before you discuss their situation, or any aspect of their plan, with another person.

Review the following practices that will help you maintain client confidentiality and privacy.

• Ensure you have the client’s consent for collecting, storing, or distributing personal information.
• Securely store client information in a manual or electronic filing system.
• Limit access to client files, plans, or other information.
• Restrict written records from being removed from your work premises.
• Adhere to your workplace policies and procedures on client privacy and confidentiality.

Of course, as a counsellor, you may face situations where disclosure of a client’s personal information is necessary to protect the client’s safety or the safety of others (limitations of confidentiality). You should always discuss any concerns about client safety with your supervisor or the case manager to ensure you do not breach the client’s right to privacy.

The Privacy Act 1988 (Cth) contains a number of provisions that govern the collection, storage, protection, use, correction to, and disclosure of personal information. Your workplace policies and procedures will be consistent with these principles. It is therefore essential that you keep your client’s details and records private and implement systems to ensure their records remain safe and protected.

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Follow Organisation Policy and Protocols

The individualised plans, counselling plans, client documents, records and reports that you use are considered a legal record of the services provided.

Your organisation will normally have policies and protocols in place that determine:

• the different types of information that must be documented
• the timeframes in which documents must be produced, reviewed, and updated
• the people responsible for completing and maintaining documentation
• how documents should be written and formatted
• how documentation and client information should be stored
• any specific auditing requirements relevant to your organisation.

When completing workplace documentation or writing case notes in a client’s individualised plan, it is important that you do so using professional, non-judgemental language and leave any of your personal opinions out. (A good way to approach this is to think: Will my clients be happy or offended when they read what I write?)

In addition, use the following tips for completing documentation/case notes.

• Ensure your writing is legible, understandable, and non-discriminatory.
• Use the appropriate forms and templates.
• Confirm with the client that the information is accurate.
• Clearly explain why and by whom changes are made to an individualised plan, if this has been necessary.
• Do not leave a blank on a form – write “not applicable” or “N/A” if necessary so others cannot add information without your knowledge.
• Cross writing out and place your initials under it if you make a mistake.
• Sign and date any completed records.

It is essential that you complete and update client documentation as soon as possible so that the information is kept up-to-date. This is especially important when following an individualised plan as there may be a number of people who rely on the information to provide appropriate support and services to the client. The information may also be required by the case manager, other counsellors, your supervisor, government agencies, or for legal proceedings.

Storing Information Appropriately

All organisations must ensure that client information is stored in an appropriate information system and is only accessible to people who are working with the individual and require this information. While some organisations prefer manual record-keeping systems, most organisations will use an electronic record-keeping system, making it easier to capture information, generate reports, and meet statutory reporting requirements.

You should follow your organisation’s policies and protocols about where documents and reports must be stored to ensure client information is filed in the correct location and can be easily accessed and referred to when required. This is particularly important for making sure client information can be retrieved by other relevant workers if a client returns to the service at a later time, or if their case is passed onto another worker. It also helps your organisation manage any future requests for access to information (e.g., through Freedom of Information provisions or as part of a court proceeding).

As such, most organisations require their workers to keep the client’s records for seven years after their last session – however this timeframe may vary across organisations, so it is your responsibility to familiarise yourself with the record management policies and procedures of your organisation and make sure that you store client information accordingly.

Complying with Reporting Requirements

You must always comply with your organisation’s informal and formal reporting requirements. Formal reporting generally involves formal documentation or a template completed in writing and is often used for major areas that are regulated by your organisational policies and procedures.

Examples include completing critical incident reports, counselling plans, client progress reports, or mandatory reporting of suspected or actual child abuse. Informal reporting, on the other hand, may not have such rigorous requirements and could simply refer to a conversation with your supervisor or the case manager about a client’s progress or a brief observation regarding the client.

Your organisation will have policies and procedures that you should follow when reporting an issue. The individualised plan may also contain specific instructions on when to report observations to your supervisor or the relevant case manager. Remember that some issues may require notification to external authorities.

For example, mandatory reporting legislation sets out who, when and how information about suspected or actual child abuse must be reported to the child safety authority in the relevant jurisdiction.

Other issues that may require notification to government authorities include:

• certain infectious diseases
• suspected or known elder abuse
• suspected or known child trafficking
• issues deemed to be in the public’s best interest.

You may also be required to check for any indications of other issues that may impact the safety and suitability of services and/or require referral, such as:

• misuse of alcohol and other drugs
• a history of mental health issues
• indicators of abuse, neglect or harm, including self-harm
• the client having no accommodation, employment, or money
• indications of domestic and family violence.

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The following case study demonstrates how a counsellor could comply with the organisation’s formal reporting requirements, including reporting observations to their supervisor.

In this final section of the module, you learned how to monitor the provision of support services and how to appropriately follow organisational processes to maintain a range of important reporting and documentation requirements.

Counsellors nowadays work in a variety of contexts, many of which involve supporting clients who have complex needs and are engaged with multiple services. Building upon an understanding of case management processes in CHCCSM005 - Develop, Facilitate and Review All Aspects of Case Management, this module narrowed down and focused on how counsellors play a part in the bigger scheme of individualised support planning and delivery, and the relevant considerations, skills, and processes.