Welcome to the Booth Wellness Center

The mission of the Booth Wellness Center is to provide high quality, cost-effective medical and mental health care in order to promote well-being and support academic success within the UT campus community. The Booth Wellness Center is also committed to offering wellness programs that increase awareness and encourage the implementation of healthy approaches to life, coping skills and resiliency.

The Booth Wellness Center has three major components: the University Counseling Center (UCC), University Medical Services (UMS) and University Wellness Programing (UWP). All Booth Wellness Center services are offered by licensed professionals in their respective fields and are coordinated and organized by an administrative team. The UCC primarily provides developmental, incident-based, life-adjustment and preventative counseling services using brief/short term therapy models. The UMS provides acute medical care including minor short-term incident-based care. The UWP offers wellness education to encourage service utilization, stigma reduction, and engagement of behaviors that enhance wellness.

The Booth Wellness Center provides non-emergency and incident-based services, not ongoing care of chronic conditions. It is not the intention of the Booth Wellness Center to deliver long-term or emergency services.  Long-term care, emergency care, and presenting problems beyond the scope of the Booth Wellness Center are referred to other resources including 911, Dixie Regional Medical Center, Corner Clinic Urgent Care, Doctors’ Volunteer Clinic of St. George, Family Health Care, River Road InstaCare and other area providers. The Booth Wellness Center also offers referral services and coordinates wellness presentations to campus and community groups.

Individuals currently enrolled in courses or currently employed by UT are eligible for Booth Wellness Center services. Services may begin up to one week prior to the first day of classes once registration has been verified. During Summer Semester, clients who were already utilizing the Booth Wellness Center services during the previous Spring Semester and are enrolled in the next Fall Semester are also eligible for services.

The Booth Wellness Center is a part of the UT division of Student Affairs. The Booth Wellness Center falls under the supervision of the Associate Vice President of Student Engagement (Dean of Students). The HCC has the following organization:

• Front Office

The Front Office staff includes 3 front desk receptionists and a student worker. Most administrative functions of the Booth Wellness Center are conducted by the Front Office Staff (e.g. answering phones, scheduling all initial appointments, rescheduling appointments, and filing). The front desk staff are the first line of interaction with our clientele and are often act as a repository of information for the students, staff and faculty as they navigate available services at the Booth Wellness Center, on campus and in the community. The Booth Wellness Center Director manages the hiring, development and performance of the Front Office Staff. The Front Office Staff day-to-day operations and scheduling are overseen by the Booth Wellness Center Support Specialist (Office Manager).

• Medical Services

All Booth Wellness Center Medical Services Staff must be medically licensed in the state of Utah or be a supervised trainee of a Booth Wellness Center licensed staff member. Presently, the Booth Wellness Center’s Medical Services staff includes a Medical Doctor, 3 Advanced Practice Registered Nurses, a Registered Nurse and Nursing Trainees. Due to the small nature of the Booth Wellness Center, there may be times or days where there is only one medical professional at the Booth Wellness Center. The appropriate level of care, based on the medical professional’s training and licensure or certification, will be provided by the available medical professional on staff. When trainees are present in the Booth Wellness Center a medical professional will also be present to provide supervision and support.

The Medical Staff report directly to the Booth Wellness Center Director. Medical Staff schedules are overseen and scheduled by the Booth Wellness Center Support Specialist (Office Manager). If the Director is not available, the Medical staff will report to the Booth Wellness Center Support Specialist (Office Manager).

• Mental Health Services

All Booth Wellness Center Mental Health Services Staff must be licensed to offer mental health therapy in the state of Utah or be a supervised trainee of a Booth Wellness Center licensed staff member. Presently, the Booth Wellness Center’s Mental Health Services staff includes 2 Clinical Social Workers, an Advanced Alcohol and Drug Counselor and Mental Health Trainees pursuing graduate degrees and supervised experience (e.g. Psychology, Social Work, Marriage and Family Therapy, etc.). Due to the small nature of the Booth Wellness Center, there may be times or days where there is only one licensed mental health professional at the Booth Wellness Center. The appropriate level of care, based on the mental health professional’s training and licensure or certification, will be provided by the available mental health professional on staff. When trainees are present in the Booth Wellness Center a licensed mental health professional will also be present to provide supervision and support.

The Mental Health Staff report directly to the Booth Wellness Center Director. Mental Health Staff schedules are overseen and scheduled by the Booth Wellness Center Support Specialist (Office Manager). If the Director is not available, the Mental Health Staff will report to the Booth Wellness Center Support Specialist (Office Manager).

• Wellness Programing and Outreach Services

Wellness and Outreach programming are a part of all Booth Wellness Center staff responsibility. Presently, the Booth Wellness Center’s Wellness Programming and Outreach Services are coordinated and organized by the Booth Wellness Center Outreach Coordinator with assistance and support by the Booth Wellness Center Support Specialist (Office Manager), student worker and graphic designer. Wellness and Outreach programming is overseen by and the responsibility of the Booth Wellness Center Director. Wellness and Outreach programming scheduling of the staff is managed by the Booth Wellness Center Support Specialist (Office Manager).

Booth Wellness Center adheres to the ethical principles of the American Medical Association, American Psychological Association, American Association of Marriage and Family Therapists, the American Counseling Association, as well as all Utah state medical and mental health licensing boards. Please remember that the client folders, schedule books, Medicat, computer or digital data, or any personally identifying information are strictly confidential material. All contact with clients and potential clients is treated as confidential information.

No confidential information may be released to anyone without the written consent of the client unless one of the following conditions occurs:

•         The client is in imminent danger of harm to self or others and notifying medical or law-enforcement authorities is necessary to insure the client’s or other’s safety.

•         The counselor has reason to suspect any of the following**:

o   Child abuse, neglect or dependency

o   Abuse of the elderly (dependent)

o   Abuse of a disabled person

o   Sexual exploitation of a client by any mental health worker

•         Second or third hand reports of child or elderly person, or disabled person abuse should be discussed with a supervisor. Reporting may be appropriate.

•         Subpoenas received by individual staff members should be brought immediately to the attention of the Director. In the absence of the Director, notify the Dean of Students.  They will contact the University attorney in order to review the subpoena and consult about options for responding. Do not release any record without consulting the Director.

**While the counselor’s mandatory reporter status should be discussed at the initial session, the counselor should discuss these conditions again with the client if any of them are suspected during the counseling work. Counselors may discuss the situation with their supervisor or the Director before reporting and/or may arrange to report with the client, if that is agreeable. To report child abuse call 855-323-3237. To report adult abuse call 800-371-7897.

Strict maintenance of confidentiality is critical to our clients’ comfort with their use of center services, as well as to conform to ethical principles and federal and state laws. All possible efforts are made to maintain both the practice and clients’ perception of confidentiality, in terms of both record-keeping and day-to-day office interactions. Each client is given a copy of the Client Information Sheet and the center’s Notice of Privacy Practices (HIPAA form) at the initial session and should have already signed them, but you may be requested to answer questions about our privacy and services by the client.

Both the identities of our clients and all identifying information about them are confidential.  We respect clients’ wishes that others do not know of their visits to the center. We cannot confirm or deny if any person has used our service at any time, without a release.

Clients are not permitted to view the appointment scheduling data (i.e., Medicat computer screen) for any reason. Our scheduling software, should be turned off every time you leave your office for more than a minute. Client files are strictly confidential and should not be taken out of the center or kept in your office overnight. Before you leave the center each day, all files and any other items containing client information must be returned to the front office staff to be secured.

Client names are not used in the reception area, halls or open offices when any other client is in the Center. Clinical and front office staff should discourage any public discussion of client problems. Please be aware of your surrounding (e.g., where you are, what you are saying) when you discuss issues concerning clients. All discussion of client issues should be done behind closed doors, as we must always protect their privacy.

If a client appears at the front office for an appointment (or as a walk-in) who is physically distraught, crying or loud, they may be asked to use an empty therapy office as a waiting room. This is to protect their privacy and dignity, as well as the psychological comfort of other clients using the waiting room.

Any suspected breach of confidentiality must be reported immediately to the Director or Dean of Students, so that action can be taken to minimize further disclosure of information and manage discomfort to the individual(s) involved. Any person working in the center, clinical or clerical, who is responsible for violating client confidentiality, may be subject to dismissal from duties in the center, depending on circumstances. Risks include legal, professional, or employment sanctions.

Booth Wellness Center ascribes to the philosophy and intent of the federal HIPAA and related state legislation regarding protection of private health information of clients. HIPAA has now increased client’s rights of access to their records and of notification of how their private health information (records) is used through publishing of our privacy rules and procedures. All employees, whether full-time or part-time, volunteers and students must be trained in the current HIPAA guidelines and are bound to work and act ethically and legally within those guidelines.  FERPA (educational privacy act) may apply, as well. If at any time you have questions about policy/procedures, HIPAA, or other state legislation regarding client privacy, please contact the privacy officer or Director at the Booth Wellness Center.

Some specific applications of HIPAA to our center include:

1.      entry and exit from our spaces, especially client areas, must be controlled:

a.       All clients must be escorted at all times in the client areas, so please come out a get your client, as well as, walk the client back up to the front.

2.      We are required to do our best to get every client to sign the Receipt of Notice of Privacy Policy form, though occasionally one will refuse, not understanding that it is not a release of information. It merely states how we operate. The signature simply acknowledges that they received a copy, no more or less. Some clients believe it is somehow a release of information. We will see a client if they refuse to sign it, but we must make a clear note of how and how many times we tried to get that form signed by the client.

3.      ALL information with PHI (Protected health information) or anything that would indicate a specific client is protected. (see below.)

4.      Booth Wellness Center maintains HIPAA compliance as this has become the standard against which centers are measured.

Requests for release of information should be accepted and acted upon only if the request is a signed original and specifically names the UT Booth Wellness Center as the agency to release psychological and/or medical records. Photocopies may not be acceptable from agencies or persons outside the university. Forms, which do not name the UT Booth Wellness Center specifically and release of medical and/or mental health records specifically, are not generally acceptable. If information is to be released to the UT Booth Wellness Center, released by us, or exchanged between the center and another agency or clinician, the client must complete and sign the Consent and Authorization to Release Information Form.

Before contacting a client, please double check the Intake Form for the client’s permission and preference(s) for the means of contacting them. It should show which phone number to use as the primary contact number and whether it is okay to leave a message. When it is necessary to leave a telephone message for a client, the name of the center should not be used. Only the front staff member or therapist first name and phone number will be left for them to call back, unless we have specific permission to use the Booth Wellness Center name. Only leave a message with another person for a client when permission to leave the message with that individual has been obtained in advance. We try to not use e-mail if other sources of contact are available, but in some cases, it may be the only means to contact a client (with their permission as indicated on the Intake Form). Texting and e-mail may not represent the most secure means of communication. Ultimately, however, this decision is usually up to the client.

The client-counselor relationship legally and ethically is a strictly professional one, thus dual relationships should be avoided. Once a professional relationship is established, it must remain professional during treatment and after termination. All clinicians in the center are held to the same professional standard ethically. Caution and good judgment about boundaries should be used when any unintentional social interaction takes place between you and your client. Under no circumstance can a sexual and/or romantic relationship take place. This is clearly unethical, illegal, and grounds for immediate dismissal from the Booth Wellness Center. Even the suspicion of a violation of this rule may result in suspension of duties. Also, state licensing boards and professional associations may be contacted as required.

University provides professional liability insurance for clinicians doing their professional work at the center.

If any ethical dilemma is suspected or presented, you should consult immediately with the Director. In these cases, proactive actions, awareness of self, and early management of any potential problem are critical. When in doubt, consult as soon as possible!

Please recognize that this will change with the inclusion of the new MFT Program. Currently, normal service hours for the Booth Wellness Center are from 9:00 a.m. to 5:00 p.m. Monday through Friday. Front Office Staff arrive at 8:00 am to prepare the center for opening while providers of Medical and Mental Services arrive at least 15 minutes before their first appointment. Last appointment or check-in times will be at 4:00 p.m.

The Center will be closed on weekends and during University designated holidays. Provider service hours may vary from semester to semester and may include changes in service hours depending on demand for services, university meetings and other campus responsibilities.

All office supplies and equipment will be ordered by the Booth Wellness Center Support Specialist (Office Manager) with approval from the Booth Wellness Center Director. The Director ultimately maintains the budget and fiscal operations of the Center Clinic.

Students are charged Student fee per semester that is allocated to the Booth Wellness Center. Students are not charged any additional fees for mental health or medical appointments provided at the Booth Wellness Center. Faculty and staff are charged $35.00 for each appointment.  Medical services beyond the appointment (e.g. labs, testing, etc.) are charged at the lowest feasible price. Condoms are also provided at no charge.

Hard copy items will be maintained in a file until a copy of the items have been uploaded into the filing system in the EHR. Hard copy items that need to be added to the “SCAN AND FILE” drawer for front office staff to scan and attach to the client’s file in the EHR. Eventually, all client files will only exist in the EHR and only minimal paper files will be maintained at the Booth Wellness Center.

If you are working with a paper file, you must return the file to the front office by 4:50 pm.  After you have seen your clients and written your notes in the EHR, place your files face down in the appropriate return file drawer in the front office island or if files need to be scanned, in the drawer below the scan. Files can NEVER be kept overnight in your office. Files must be locked and secured each night by front office staff.

Only the Front Office or Administrative Staff should file hard copy files. If you need a file, please request it from a member of the Front Office or Administrative staff. Client data is available to all staff on a “need to know” basis only. You are allowed to view other clinicians’ client files ONLY when permission has been given by the responsible clinician, client/patient or Center Director.

Training will be given for the use of Medicat, which is the EHR software program used to schedule clients and write notes. A Medicat User Guide will be provided as a reference tool.  Please let the Booth Wellness Center Director know if you encounter problems with the software.

Users will have differing levels of access to information contained in Medicat. Providers will be able to view their own schedules and client notes. When done with Medicat, close it so no one will be able to view the confidential information contained within it. Do not share your password or login session with others, as this is a breach of confidentiality and all actions taken by that person will be audited to your account. IMPORTANT: Never leave your Medicat password lying around or displayed, as this defeats the purpose of this very important security measure.

An Electronic Health Record Service, Microsoft Office products and Internet access is provided on Booth Wellness Center computer terminals for Booth Wellness Center staff member use. Computer access is controlled by user accounts assigned to each staff member. Computer use during center hours should only be for center related work.

The Internet can be a useful research tool for our client’s benefit and your professional development. Inappropriate web content (e.g., pornographic or similar websites) should be strictly avoided at all times. Do not add any software or store any files on these computers or change their settings without permission from the Director or Support Specialist (Office Manager).

NEVER save any client data to the hard drives. Client data should only be maintained in the EHR or in a hard copy file until uploaded to the EHR. Caution must be extended to printing any materials that contain confidential information (e.g., case notes). Immediately retrieve printed confidential information from the printer, secure it and then shred it when you are done.

The Booth Wellness Center has a combination fax, scan and copy machine located in the front office. The copy and fax machine is for the purposes of the Booth Wellness Center related (i.e., client and patient related) work. Consult with the Support Specialist (Office Manager) for any print or copy jobs over 20 pages. Unless specifically approved by the Director or Support specialist (Office manager), the machine is not for personal use, homework, or responsibilities related to other departments.

Remember you are a professional and a part of the Booth Wellness Center staff. All Staff should show professional demeanor whenever they are in the center. As such, your behavior reflects on Booth Wellness Center whether you are officially seeing clients or just stopping by. Your professional status should be reflected in appropriate dress, language and behavior, and presentation of a positive image through following agency protocol.

The Booth Wellness Center strives to provide a professional and safe environment for clients to explore sensitive areas in their lives. How we dress contributes to the environment that our clients experience. It is important that our clothing styles do not create an overly casual, distracting, or sexualized environment. Research has shown that clients perceive professionals as more credible and that more positive outcomes result when a professional image is conveyed to the client. While we want you to integrate personal style with an overall level of professionalism, there are some minimum criteria for attire. Any clothing, hygiene, or lack thereof that may be distracting in any way is not appropriate dress & hygiene for offering Wellness services. Here are some guidelines for appropriate appearance and attire:

1.      Avoid wearing suggestive, too casual, and/or revealing attire (e.g., visible cleavage or stomach, overly form-fitting clothing, athletic clothing, shorts, mini-skirts, “flip flops” or T-shirts, especially anything that mimic underwear or have slogans, novelty buttons, baseball hats, etc.).

2.      Avoid exposed undergarments. Be thoughtful about how you position your body when wearing skirts so that underwear is not exposed. You should be able to reach up to the top shelf and lean down to the bottom shelf without exposing yourself.

3.      Avoid clothing that requires constant adjusting to comply with these guidelines.

4.      Maintain your clothing so that it is clean, intact, and reasonably wrinkle-free.

5.      Hair, sideburns, moustaches, and beards should appear to be clean and well maintained.

6.      Personal cleanliness, overall hygiene, and being odor free are very important.

7.      Avoid wearing distracting body piercings (e.g., tongue studs, gauges) and distracting tattoos, and they should be removed or covered up for the time you are at the center.

8.      NO JEANS from Monday to Thursday. On Fridays Jeans are allowed if you wear a UT branded top to support the university. If wearing jeans on Friday, they must be clean, nice looking, not ripped, and preferably wrinkle-free.

If you are uncertain about how appropriate an outfit you are wearing is, please consult with the Director or Support Specialist (Office manager). There are some dates and events when more casual clothing will be the allowed attire. The Director or Support specialist (Office manager) will make you aware of these occasions.

Special attention should be given to your behavior while in the front office. The Front Office staff must keep up with many activities affecting clients, faculty, campus, and our own staff here at the Booth Wellness Center. This is a multifaceted job and requires a lot of attention to detail. It is important that you do not stay in the front office area longer than necessary when conducting business. Try to avoid prolonged gathering there and sitting in a lounging fashion around the work area. Do not bring your lunch or meals to eat in the front area, if you need to eat a meal please use an open office or the break area. Please do not use it as a social area. Try to be conscious of this distraction and make your visits as short and as quiet as possible. If you need to talk to someone at length, just ask to speak them away from the front office (e.g. in an office, in the conference room). Such practice also ensures confidentiality, as no client names or issues should be discussed in open areas.

Here at Booth Wellness Center, the expectation is that you will be prompt for all your activities here. Multiple absences or tardiness can be grounds for sanctions and/or dismissal from Booth Wellness Center. In the event of a problem, the offender will be put on probationary status with any further problems resulting in one or more of the sanctions mentioned above.

On occasion, a period of leave or schedule adjustments may be granted, as the situation warrants. If you need to miss your scheduled time or to be gone more than a few minutes, talk with the Director or Support specialist (Office manager) first. Approval of any pre-planned time off or schedule adjustment must be granted at least 2 weeks before the change is to occur. Please submit any request for a schedule change via email.

First, we all work toward making Booth Wellness Center a positive, energetic, and supportive environment in which to work. It is amazing at how harmful even one person being negative or inappropriate can be to the work environment. One of the primary concerns of Booth Wellness Center is to protect both clientele and staff from foreseeable harm from individuals, groups, or the work environment. Impairment may be evidenced by behavioral, cognitive, and emotional problems of an individual that negatively impact performance of duties, counseling or supervision activities, the work environment, and/or interactions with others. Behaviors, such as using foul language toward anyone in the center, being disrespectful, being intolerant of individual differences, coming to the center intoxicated or high, raging at others, etc. are some examples, but you probably already know what the proper conduct should be. Breaking confidentiality, not showing for appointments or supervision on time, and a myriad of other issues also may represent ethical breaches as well as being generally unprofessional. If you have a problem with another individual in the center, please consult with the Booth Wellness Center Director or Dean of Students.

Thus, in the event that a staff member is thought to be “impaired,” regardless of type (whether from psychiatric or emotional difficulties, behavioral problems, chemical or medication related, or other types of problems which affect the performance or reliability of executing one’s duties), the Booth Wellness Center, in compliance with UT standards (for employees), retains all options to take action, including, but not limited to, deferment, dismissal, probation and/or referral of the individual for appropriate assessment and remedial care, as appropriate. In the case of a licensed professional, contact with the respective professional board may be ethically required. If you have any questions about this policy, please consult with the Booth Wellness Center Director or Dean of Students.

All Staff members of the UT Booth Wellness Center will receive a bi-annual evaluation. These evaluations will be based upon the Booth Wellness Center policies and the UT Core Competencies. The evaluation process will follow the UT Staff evaluation process. Please review the webpage to better understand the process.

Performance evaluations are a review, discussion, and assessment of staff member’s performance of assigned duties and responsibilities. It is a tool meant to help enhance the efficiency and efficacy of the UT Booth Wellness Center and a staff member within the Booth Wellness Center. An annual evaluation provides a forum for exchanging ideas, promoting staff personal and professional growth and achievement. It is also essential in identifying training and development opportunities as well as recognizing growth and enhancing performance.

Each Booth Wellness Center team member is contracted to work a specified number of hours per week at the center. Each Booth Wellness Center team member is under a different contract, but all are expected to attend a team wide weekly meeting. Team members can arrange with the Support Specialist (Office Manager) to determine their individual work hours. All practitioners are expected to arrive 15 minutes before their first appointment of the day.

Due to the heavy demand on service, Practitioners are expected to complete work with patients/clients as efficiently as possible, while maintaining professional standards of care.  Appointments for mental health are designated as an hour long and includes 45-50 minutes of therapy with 10-15mins for time for note taking, note review and preparation time between appointments.

If you have open times on your schedule or a client does not show up for an appointment, these are considered available times for the scheduling of appointments (e.g., “walk-ins” or urgent clients). Therefore, you should be available at the Booth Wellness Center during all scheduled hours for “urgent-care coverage” or other center responsibilities (e.g., prep work, note writing, outreach planning, supervision, professional development activities, etc.). If you must leave Booth Wellness Center during your scheduled hours for more than a few minutes, let the front office team member know that you are leaving and when you will return. You are expected to be here during all of your scheduled hours at the center unless special arrangements are made in advance (see Absences or Being Late). Approval of any pre-planned time off or schedule adjustment must be granted at least 2 weeks before the change is to occur. Please submit any request for a schedule change via email.

For everyone’s protection, including yours, client appointments will be made only during times when the Booth Wellness Center is officially open. Also, you should never meet any client outside of the center for any reason. This rule applies to all Booth Wellness Center employees. A violation would have ethical and possibly legal implications and any violation of this rule will have severe repercussions.

Scheduling Appointments

Most clients are seen by appointment only and scheduled by the front office team, with the exception of urgent care. The Front Office Staff is responsibility for scheduling of initial appointments and is overseen by the Support Specialist (Office Manager).

If a practitioner identifies a needed follow up or continuing care they are expected to reschedule those appointments with the client, in their office, before the client leaves the clinician’s office. This allows the client freedom to exit the Booth Wellness Center directly after their appointment without needing to go the front desk (especially if their session was emotional for them) and it frees up the front desk for other duties.

It is important that this is done in Medicat in a timely fashion so that a double-booking does not occur. An open appointment time that is not filled within a day of the last appointment is open for new appointments to be scheduled by the front office team. “Double-booking” is not only a hassle for you, but it affects clients negatively and it appears unprofessional. If you become double booked due to your failure to reschedule you are responsible to resolve the scheduling conflict yourself.

The front staff is responsible for taking attendance of client appointments and will indicate the status of the attendance in Medicat. You are responsible for greeting your client in the waiting room and escorting them back to your office, as well as escorting them back to the front at the end of each session. (This is a HIPAA requirement).

While Medicat might let you know whether your client is here; please walk up and check visually to see if your client has come to the appointment, if it more than 7 mins after the appointment time. Clinicians should not assume a client is not coming if they are a little late. An appointment will be counted as a “no show” if the client has not arrived 15 minutes after the scheduled appointment time. Remember that if a client is late for their appointment, YOU still end the appointment at the scheduled time in order to stay on schedule.

We try to protect and limit the time commitment each team member has each week, however, there may be a few exceptions. While a rare event, professionalism and ethics might dictate that additional time may be needed to manage your clients’ needs. For example, you might need to come by the counseling center and call or see a client due to serious problems (case-management) outside of your normal hours at the center. Anytime this occurs, please discuss/consult about this with the Booth Wellness Center Director.

When a client fails to come for an appointment without calling first, this is referred to as a “no show.” After one no show, the client has 24 hours to contact the Booth Wellness Center to reschedule. If this is not done, he/she will be charged a no show fee If an ongoing client cancels twice consecutively, they will not be rescheduled again until they have communicated with their clinician. The clinician should indicate the need to speak with the client in the note section of the client’s profile. These procedures are included in the intake paperwork.

For clinical staff there are a number of record keeping and scheduling duties inherent in the process of providing services. Medicat is the program we use to manage appointments, schedules, and notes. It is critical that you keep your case notes up to date All notes should be completed within 1 (one) business day of the client’s appointment time.

Please remember to note clients who no-show or cancel, and include any information that is relevant (e.g., client called saying he/she had car trouble and will call back to reschedule).  Please keep in mind that record keeping has several purposes and should be useful, not merely an exercise. Notes that report everything during an appointment are not useful (e.g., he said…and then I said… ). Some factual information may be important, but in general, notes should summarize issues, goals, plans, and outcomes in order to provide direction.

You will be doing your notes for each client in Medicat where pre-existing forms for notes are provided. All client contacts (e.g., phone calls) and consultations regarding the client’s case (e.g., consultation with physician for whom you have a signed release by the client to consult with) should be documented in the client’s file in Medicat.

Expect that a client record may be read by others (e.g., your supervisor, the client, his/her attorney, the court, another professional) under certain conditions. Therefore, it is very important that you be careful of terminology or jargon used in your notes. Use client words (quotes) or specific behaviors as descriptors where possible. Limit speculation and theoretical musing to those contributions that give direction to the treatment/assessment.