5.3 – Maintain Client Records
Purpose & Context
Career Development Professionals (CDPs) maintain all documentation relevant to the delivery of career development services. Documentation is required to support an evidence-based practice including planning, implementing, and evaluating the services delivered.CDPs are accountable to clients, employers, and funders for the services they deliver. Well-maintained records help protect CDPs from professional liability in the event they become the subject of legal or ethical proceedings. CDPs maintain accurate, current, and pertinent records of services, as may be required. The records must contain sufficient detail for regulatory and administrativereview of services.CDPs can only use client information for the purpose for which it was intended. Maintenance of appropriate records may be needed for institutional, financial, and legal purposes.
CDPs make reasonable efforts to protect against the misuse of records. Where CDPs are employed by an organization, or engaged as contractors, they should consider relevant organizational policies and procedures.
Effective Performance
Competent career development professionals must be able to:
- P1. Comply with privacy and record-keeping policies, guidelines, and legislation
- P2. Maintain client records and information, such as:
- Identifying data, e.g. name, address
- Informed written consent
- Permission to release information
- Relevant historical and demographic information on client, client’s family and significant others, as required
- Referral information, if applicable
- Intended goal, objectives, and outcomes
- Dates and types of services
- Results of assessments
- Progress notes, e.g. details of interventions, training services provided, location where services were
delivered, date and duration of interaction, reason for interaction, action taken, next steps - Intervention outcomes
- Evaluation outcomes
- Incident reports, e.g. medical emergency
- Referrals to other professional resources, e.g. follow up and feedback, recommendations
- Reason for termination of services
Knowledge & Understanding
Competent career development professionals must know and understand:
- K1. Code of Ethics
- K2. Legislation, e.g. Personal Information Protection and Electronic Documents Act (PIPEDA)
- K3. Organizational confidentiality and record-keeping policies and procedures
Contextual Variables
Competent career development professionals must be able to perform this competency in the following range of contexts:
Records may be created and maintained in a variety of media (e.g. paper-based, electronic systems).
Glossary & Key References
Terms
Industry-specific terms contained in the standard defined here, where applicable.
Information Sources and Resources for Consideration
Context Rating Scales
Criticality
Q: What is the consequence of a professional being unable to perform this skill according to the standard?
Frequency
Q: How frequent and under what conditions is this skill performed?
Level of Difficulty
Q: Under routine circumstances, how would you rate the level of difficulty in performing this skill?
Time Required to Gain Proficiency
Q: What is the average length of time or number of repeated events that are minimally necessary for an individual to become proficient in performing the skill to the standard?
To become fully proficient in this competency, a career development professional should perform this competency proficiently within three months.
Autonomy
Practitioners typically perform this competency without supervision, and alone.
Automation
It is somewhat likely that this competency will automate.