Counselor´s Record Keeping System

A clear, well-organized record-keeping system is essential for counselor who provides treatment, nutritional assessment and consultation services. But setting up such systems can be challenging. For one, a counselor need to attack the fine balance between the need to maintain client privacy and confidentiality and the need to communicate with insurers, other treating professionals and larger health systems. Counselor’s records must also follow the state and federal laws (King & Klawitter, 2007). . In addition, a counselor needs to plan for retirement and the eventual disposal of records. In order for counselor to have these records, information needs to be documented. Some of the things that need to be documented include counseling sessions, patient family history, payment history, emergency contact and patient’s vitals, privacy act, informed consent, past and present medical history.

All information for all clients are kept confidential and these can be schedule of appointments, counseling session contents, any information that contain records and the outcome of the counseling are confidential by State law (King & Klawitter, 2007). This type of confidential services is provided and maintained by all medical personals. Josephine’s record consists of both paper file and electronic database components. Her records are much secured, physically and electronically, thus protected by the same confidentiality and privacy laws. Most counseling centers have patients that see more than one counselor; it can be a psychologist and a counselor depending on the issue at hand. In this case there will be sharing of information in order to be able to consult with each other to deliver and provide effective services.

The only members that can ...

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...counseling requirement. Other negative obstacles that can be identifies include the feeling of depression, sadness and or anxiety. Using her culture, she may also find it hard to tell her mom that her cooking is causing problems for her.

As her counselor, I will have to work with her through any uncertainty by supporting her efforts to change and helping her identify inconsistencies between her goals, and values. Involving her in activities, such as support groups, can also be effective. In regards to her mom, I will suggest maybe get herself in to the kitchen and help her mom on the cooking. As she continues to do that, she can suggest taking something out and adding more healthy choices. With her sadness, depression and anxiety, I will suggest she starts to record when these feelings start to come, at what time of the day and how often it appears during the day.