Counselling Record or Notes: Clinical, Ethical, Legal, Fiscal, and Risk Management Dimensions
Oramah, Emmanuel U, Ife Psychologia
Counselling process is a function of different issues that contribute to its uniqueness. Counselling records remain a veritable issue that benefits the counsellor, the client, and the entire counselling process. This paper, therefore, discussed counselling records as one area that requires adequate consideration from the counsellor. It is contended that counselling records will serve its purposes when its different dimensions are known and utilized by the counsellor. These different dimensions discussed were the clinical, ethical, legal, fiscal, and risk management dimensions. They point to the multi-purpose nature of a counselling record.
Keywords -Counsellor, records, clinical, ethical, legal, fiscal, risk management
Counselling process involves different things that define its uniqueness. Counselling records or notes remain veritable constituents of counselling relationship and thus contribute to the uniqueness of counselling relationship. Though counselling records reflect actions of the client and the counsellor, its creation is the sole responsibility of the counsellor. Quite a number of practitioners and authors elsewhere have enthusiastically affirmed the utility of counselling records for the overall course of effective counselling services delivery (Zur, 2011a; Remley 8c Herlihy, 2005; Schaffer, 1997; Pizza 8c Baruth, 1990, Snider, 1987). The overall theme running through the expositions of these scholars is the need for counsellors in both private and public practice to embrace the creation and utilization of counselling records or notes for every client as medium for exhibiting the required professionalism. It could portray the counsellor as an effective manager of clients' information (Agbe 8c Akume, 2006).
Meanwhile, the exposition of the uniqueness and the necessity of counselling records or notes in the whole gamut of counselling process have not received much attention in the local counselling literature in the Nigeria. It does not seem to be receiving adequate attention in the counsellor education program in the country either. Towards full appreciation of the usefulness of counselling records or note, which undoubtedly could become unknown to counsellor trainees, efforts have been made in this paper to identify and explain those defining dimensions or segments of counselling records. The discussion below therefore, focuses on the meaning and nature of counselling records, the clinical, ethical, legal, fiscal, and its risk management dimensions.
Meaning and Nature of Counselling Records
A particular counselling encounter between a counsellor and a client involves diverse activities that could include initial welcoming by the counsellor, provision of structure, client's presenting problem and verbalization, counsellor's assessment and case formulation, application of treatment and many more. These different activities could be noted down or recorded by the counsellor either by writing or through some electronic device. The end result is counselling records or notes. Counselling records thus pertain to a counsellor's efforts at articulating and retaining those important activities that transpired within a particular counselling encounter. They represent an intentional and a systematic articulation of sequence of events or actions that show the direction of treatment from the initial to the closing stages of the counselling process. Thus, Remley and Herlihy (2005:119) assert that in the context of counselling relationship "records are any physical recording made of information related to a counsellor's professional practice". Purves (2005) notes that records should be considered to be anything that is kept in the client's files and notes and are a record of the content of individual sessions. This is in line with Egbe-Okpenge (2006:40) assertion that "a record is any information about an event or series of events that is either written or stored in a file or computer". …