Client case notes are the confidential records that you create about the client and their treatment when on placement. They must be submitted in electronic form only. No hardcopy case notes can be accepted by CMI.
It may be suggested by your supervisor or agency rep that some hard copies will be stored at the Placement and some case notes and other related documents can be submitted to CMI. If the placement agency can store all client case notes and related documents securely in accordance with the Health Records Act 2001 then that is best. Please do not separate client case notes between locations. School placements are less likely to have this type of secure storage system and in these instances, the client case notes must be submitted to CMI (PracSuite).
Please note: once you have finished your placement and all of the client case notes are in PracSuite, you are no longer the provisional psychologist or counselling student for any clients that you saw while on placement. If you are contacted by a client or guardian/parent of a client after you have finished, please refer them back the agency or school where you saw them. If you receive further communication from the client or guardian via email, please refer them on to the CMI Clinic Director and advise them that you are no longer handling their case.
PracSuite Account
If you are placed at a school (or agency) that does not have any secure internal client case notes / client file storage facilities in accordance with the Health Records Act 2001, students are required to be set up with a CMI PracSuite account. Please speak to your Placement Coordinator about arranging an account for you. NOTE: if you have had an account already set up for a previous placement, your Placement Coordinator will need to re-apply for your access to be re-activated to cover your current placement.
Once an account has been requested, you will receive set up instructions and access to the user guide. Once you have set up your account, you can start creating your client case notes directly into PracSuite.
In line with ethical requirements for record keeping and continuity of care, students are required to make contemporaneously client case notes (during, immediately afterwards or within 24-48hrs following the client session).
Client case notes are the confidential records that you create about the client and their treatment when on placement. They must be submitted in electronic form only. No hardcopy case notes can be accepted by CMI.
You are required to always complete one client case notes cover letter (per agency/school not per client) even if the case notes are being stored at the placement agency or school. The case notes cover letter must be submitted within 7 days from the completion of your placement.
Any questions, please email placements@cairnmillar.edu.au for any queries around this process.
Note: If you are located at Gippsland Community College – your case notes are to be created and stored on CMI Clinic PracSuite. You will still need to complete the case notes cover letter and submit it to Canvas. Please speak to your Supervisor and the CMI Clinic Director for more on this.
Examples of what may be included within the submission of your case notes (these may differ slightly per placement):
- All case notes / session notes (note: these do not require the signature of your Supervisor but should have been sighted frequently by your Supervisor throughout your placement to ensure they meet adequate standards).
- Above summaries.
- PROCAP, PROC, SOAP notes.
- Complete assessment reports.
- Record forms for assessment reports (e.g. WISC record forms) include the title page and any other important pages relevant to the overall assessment of the client.
- Consent forms (for psychological services and recording sessions)
- Copies of drawings completed by client (if applicable) if relevant to the overall treatment of the client.
The following only occur if the client case notes are being stored with CMI:
Provide the school with the following:
- Copies of consent forms.
- A brief Client Counselling Summary (max. 2 pages per client) of your client case notes / assessment reports per client for their records. If a client requires a guardian, consent to provide a summary should be obtained from the guardian first. These should be provided to the Wellbeing Coordinator (or Student Support Services Officer (SSSO) if the client was seen by the SSSO) for secure storage. The summary should outline the most pertinent factors that will assist any future student taking over care of the client. Please do not provide copies of the client case notes eg PROC, SOAP. These must be incorporated within the summary. These may also be referred to as Termination Summaries. Please use this Client Counselling Summary template.