Client Information Management Procedure

1.0 Purpose

This procedure outlines how we manage client:

• Information Collection and handling

• Information Use and Disclosure

• Information Quality

• Information Security

• Information Openness

• Information Access

• Information Identifiers

• Information Anonymity

Specific procedures for the above regarding specific service procedures, are outlined within the service procedure i.e. Assessment or support planning.

2.0 Definition

Confidential Record or Report - A confidential record or report is one that may contain personal and/or financial information about a worker, such as medical certificates or reports.

3.0 Procedure

Information collection and handling

Transforming Kids Therapy Services aims to collect information in a useful, fair, lawful, and non-intrusive manner. Collection and handling procedures for specific procedural purposes i.e., assessment, support planning or collaboration are outlined within those policy and procedures. 

In general, we:

• Ask for permission to collect information at referral, on assessment and throughout therapy to identify and facilitate appropriate services.

• During assessment we ask for consent to collect information through observation, client information such as reports from other professionals, questionaries’ and through discussion.

• We request information on preferred language and any cultural considerations.

• Information held may also include clinical session notes, emails, transcripts of telephone conversations and work samples.

• CCTV footage is also held for 30 days before being automatically deleted. Some client videos may be held for teaching or professional development purposes. Clients are asked through the service provision agreement to ‘OPT OUT’ if they do not wish for any video footage to be used or stored for teaching purposes.

• By law client information is held for 7 years after finalizing services or until the child is 25 years old, whichever is longer.

• We request consent from clients to share any information with external providers. This consent can be withdrawn at any time through verbal or written communication with any Transforming Kids employee.

• All client information is saved under the client’s name, file name and year and arranged into client folders.

Information Use and Disclosure

• All information gathered is used or disclosed solely for the original purpose of collection, to facilitate best practice service provision for clients.

• Video footage is used for best practice service provision, ensuring quality service provision through professional reviews and training. Clients can seek to opt out of video recordings.

• When children are using Medicare Plans or Access to Allied Psychological Services (ATAPS) it is mandatory that initial and follow-up written reports are forwarded to the family doctor or to Medicare Local.

• By law, we are required to disclose information without parent permission in exceptional circumstances. These may include evidence of child abuse, issue of a court order, location of a missing person, prevention of serious and imminent threat to a person’s health or welfare or during a National Disability Insurance Scheme audit through a registered auditor.

• We are also required by the National Disability Insurance Scheme to report to the NDIS via submitting reports upon your review process. This is required and not optional.

• No personal information is disclosed to overseas persons or agencies. There is no secondary use of information for advertising or research purposes, unless otherwise negotiated.

Information Quality

Transforming Kids takes all reasonable care to ensure that the personal information we collect or disclose is accurate, complete and current. We request parents advise us if personal information we are holding is inaccurate, out of date, incomplete, irrelevant or misleading. Parents have a responsibility to provide us with updated d.

All documentation produced by Transforming Kids Therapy Services must process through our quality management procedures which are outlined with the Quality Management Policy and Procedures.

Information SECURITY

All files are confidential with access limited to employees and where necessary clerical staff for administrative purposes. Transforming Kids Therapy Services employees have been instructed on the principles of the Privacy Legislation and are committed to protecting privacy rights.

All client information is stored on a secure cloud storage system which has end to end encryption ensuring privacy and confidentiality. Our cloud storage is held within Australia as per requirements by the Privacy Acts.

Any client information is held within locked offices and filing cases throughout the day and overnight. All Computers are password protected and locked when unattended and overnight.

Client sensitive information is held within red boxes and are not allowed to be in accessible and unsupervised areas at any time.

Employee offices are always closed and protected by number locks to limit access.

Information OPENNESS

Transforming Kids seeks to provide parents, carers and all parties involved with our client’s information regarding skill development, the brain and any other therapeutic information. We seek to provide this information transparently and free, allowing unrestricted access to knowledge and information to assist our client’s progression. We seek to collaboratively and cooperatively manage and make decisions with families and all parties involved.

All clients are informed of how their information is managed through:

Transforming Kids Welcome Pack which details privacy and information management.

Service Provision Agreement and Privacy Consent Forms

Service agreement Forms

Information ACCESS:

Parents or legal guardians can request a copy of information about their child generated by Transforming Kids Therapy Services. From the age of 18 years, young people can request a copy of information about themselves. Requests to access information should be made to the Director, Bridie Travers. Information about children who are ‘Under the Care of The Minister’ can only be provided with permission from the child’s caseworker. Information cannot be provided in the case of Medico Legal assessments.

Information IDENTIFIERS:

Transforming Kids Therapy Services does not use or disclose an identifier that has been assigned by a Commonwealth government ‘agency’ i.e. Tax File Number, Medicare Number.

Information ANONYMITY:

Parents may choose to withhold information about their child, or for themselves and their child to attend anonymously or with pseudonyms, with the understanding that this will probably jeopardize the quality of provided service.