Adventures in Clinical Record Keeping: An Easy Guide to Progress Notes

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It is a generally accepted practice, however, in the absence of such a contract, for counselors to inform clients to call or to go the nearest hospital Emergency Room for treatment in the event of a crisis. AMHCA Members: To submit an ethical concern for the committee to review or to submit another frequently asked question please sign in and return to this page.

All rights reserved. This website uses cookies to ensure you get the best experience on our website. Learn more. Skip to main content Press Enter. Log In. Skip auxiliary navigation Press Enter. Contact Us. Skip main navigation Press Enter. Toggle navigation. Date range on this day between these dates. Posted by. Frequently Asked Questions on Ethics. Question: If a client refuses to sign my treatment contract, can I then provide services to that individual?

Answer: In general, no.

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Code section I. Question: When do I have the duty to warn of a threat by my client or a duty to protect against violence that may be committed by a client? Answer: The Tarasoff duty to warn and protect against serious threats of imminent violence by a client has been adopted in various forms in state laws and licensing board Rules.

Counselors need to comply with their state law or licensing board Rules regarding the duty to hospitalize a client who is dangerous to others, in order to prevent threatened violence and to protect the potential victim. By doing this, you comply with Code Principle I. Mom and Dad are separated. I have never met the husband, and know little about him, except for information provided by Mom concerning his drug problems and his acts of domestic violence.

Can I testify as an expert witness for Mom in the divorce case? Answer: No, a counselor who is serving in a clinical role, providing treatment to a Mom and her children in family counseling, cannot also take on the role of forensic expert. To do so would violate Code principle I. A dual relationship would result if a counselor served the same client in both a clinical and forensic role. Question: Part of my practice as a counselor involves providing clinical supervision to people who are seeking licensure. What should I do to protect myself from liability, in case I am sued for the actions of a supervisee?

For example, how could I defend myself if a therapist that I was supervising was having a personal relationship with a client—without my knowledge? Answer: The best defense against any potential risk in a situation such as this is for the clinical supervisor to have a thorough Clinical Supervision Contract with the supervisee in compliance with Code section III.

Question: I have a client who is being seen in couples counseling.

His unwillingness to make a serious attempt to cooperate with counseling has been an obstacle to the process of therapy. His flirtatious remarks to me make me very uncomfortable. I feel that I should refer this couple to another therapist, but I do not want to be seen as abandoning these clients. Can I terminate my services and refer the couple out? I feel like I got something positive from reading it. Worth a read but not worth buying. Need customer service? Click here. There's a problem loading this menu right now.

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Amazon Advertising Find, attract, and engage customers. Amazon Drive Cloud storage from Amazon. Alexa Actionable Analytics for the Web. Sell on Amazon Start a Selling Account. AmazonGlobal Ship Orders Internationally. Contractors are PCBUs in their own right. Monica, a nurse at the local hospital, set up a group of keen knitters to knit clothing for babies Knitting for Babies two years ago.

At first the knitting was only donated to the hospital, where it was used for premature babies. Recently the group has grown substantially and now also knits jumpers and other clothes for older babies. These jumpers are given to Plunket and the Salvation Army to distribute more widely in the community to those in need. The demand for knitted baby clothes became so great that there is not enough donated wool. The group became an incorporated society, Knitting for Babies Incorporated, and employed Roger on a part-time basis to take care of all administration and accounting matters.

Happier Homes is a charity organisation that finds homes for abandoned pets. It is run by volunteers. Happier Homes contracts an IT specialist to create a website to promote their cause. Happier Homes has now expanded and needs someone to manage the administration of the organisation. A home occupier who employs or engages another person to only do residential work domestic work done in the home, or other work on the home itself is not a PCBU.

However, a home occupier is a PCBU if they operate a business from their home. Mary owns a small lifestyle block and wants to keep chickens and plant a large garden to provide fresh eggs and vegetables for her family of eight. The property is not connected to the town water supply.

Peter, a self-employed chef, has started his own business to provide healthy, home-cooked meals to people. Peter runs the business from his home and contracts a local courier company who employs a driver called Sandy to deliver the pre-cooked meals to customers. A PCBU must ensure, so far as is reasonably practicable, the health and safety of workers, and that other people are not put at risk by its work. A PCBU who is a self-employed person must also ensure, so far as is reasonably practicable, his or her own health and safety while at work.

The primary duty of care is a broad overarching duty. It includes, but is not limited to, so far as is reasonably practicable:. PCBUs must also maintain any worker accommodation that is owned or managed by the PCBU and provided because other accommodation is not reasonably available.

Managing health and safety

The PCBU must, so far as is reasonably practicable, maintain the accommodation so the worker is not exposed to health and safety risks arising from the accommodation. PCBUs must, so far as is reasonably practicable, provide and maintain a work environment that is without health and safety risks. PCBUs must, so far as is reasonably practicable, provide safe plant and structures, and maintain them in good condition.

It can be fixed, movable, temporary or permanent, and includes any component or part of a structure. The following are examples of structures:. PCBUs must, so far as is reasonably practicable, provide and maintain safe systems of work eg work processes. Developing a safe system of work is a formal procedure carried out by a person with sufficient knowledge and experience. It involves:. The development of safe systems of work can involve looking at the physical layout of the workplace and its access and egress, tools, plant, procedures and people eg instruction, information, training.

PCBUs must, so far as is reasonably practicable, make sure that plant, structures, and substances are safely used, handled and stored. PCBUs must, so far as is reasonably practicable, provide adequate facilities that are clean, safe, accessible, in good working order and maintained to stay that way for the welfare of workers. PCBUs must, so far as is reasonably practicable, make sure its workers and others are provided training, information, instruction or supervision to protect them from risks to health and safety.

The type of training, instruction or supervision required will depend on the nature of the work carried out and the experience of the workers, and the risk that workers and others, such as clients and customers, are exposed to. Monitoring is not a control measure to manage risk and does not replace the need for control measures to reduce exposure. Results from monitoring should be used to improve control measures where needed.

Workplace monitoring can involve measuring a hazard eg a substance, fumes, noise or vibrations arising from the work. The purpose of the monitoring is to assess the effectiveness of controls being used to minimise the risk of workers developing a work-related condition or getting injured on an ongoing basis. Health monitoring involves specific and targeted testing of the health of workers to identify potential signs of potential harm to their health and any changes on an ongoing basis.

As well as identifying the development of work-related conditions, the purpose of monitoring is to assess the effectiveness of control measures designed to minimise potential harm to worker health on an ongoing basis. In some situations a PCBU provides its workers with accommodation that it owns, or manages or controls, where this is necessary because other accommodation is not reasonably available.

If this is the case, a PCBU must, so far as is reasonably practicable, maintain the worker accommodation so that workers are not exposed to health and safety risks arising from the accommodation. There are some duties that apply to PCBUs in certain situations. These are outlined in sections 3. They expand on the primary duty of care. These PCBUs still have the primary duty of care.

However, certain duties relate to workplaces. A PCBU who manages or controls a workplace must ensure that, so far as is reasonably practicable, the workplace, the means of entering and exiting the workplace, and anything else arising from the workplace are without health and safety risks to any person. PCBUs who manage or control workplaces do not owe this duty to anyone who is at the workplace for an unlawful purpose. A builder is making repairs to a commercial property. Lines workers are carrying out a one-off repair of a power pole.

Once they complete the work and leave, it is no longer a workplace for the lines company PCBU as the workers are not usually at that location for work. There is a clarification of these duties for farming businesses or undertakings. For these, the duty of a PCBU who manages or controls a workplace applies only in relation to the farm buildings and any structures and part of the farm immediately surrounding the buildings needed for the operation of the farm.

They do not apply to the family home, or to any other part of the farm unless work is being carried out there. However, the primary duty of care to ensure people are not put at risk by the conduct of work still applies. PCBUs who manage or control fixtures, fittings or plant at a workplace must, so far as is reasonably practicable, ensure that the fixtures, fittings or plant are without risks to the health and safety of any person. This could include consideration of the potential health effects from using the plant eg the long-term use of a vibrating tool causing damage to nerves or blood vessels in the arms or hands.

PCBUs who manage or control fixtures, fittings or plant do not owe this duty to anyone who is at the workplace for an unlawful purpose. The duties apply in respect of plant, substances, or structures that are to be used, or that could reasonably be expected to be used, at a workplace. Upstream PCBUs are in a strong position to eliminate or minimise risk. Upstream PCBUs can influence and sometimes eliminate health and safety risks through designing or manufacturing products that are safe for the end user. A poorly designed or manufactured saw eg that is not guarded as outlined in ASNZ creates the risk that it may injure the user.

This risk is created by the saw designer and manufacturer the upstream PCBU. The risk will flow through to the downstream PCBU business that purchases the saw, and the workers who have to use the saw as part of a daily work activity. PCBUs who are designers, manufacturers, importers or suppliers must, so far as is reasonably practicable, make sure that the plant, substances, and structures designed, manufactured, imported or supplied as relevant are without health and safety risks when they are used for their intended purpose in a workplace.

Duties of PCBU designers, manufacturers, importers and suppliers of plant, substances and structures. Duties of PCBU installers, constructors and commissioners of plant and structures. Duty to, so far as is reasonably practicable, ensure plant, substances, or structures are without health and safety risks. Make sure, so far as is reasonably practicable, the way that the plant or structure is installed, constructed or commissioned is without health and safety risks to people who:.

This includes information about:. On request, make reasonable efforts to give the current relevant specified information to a person who carries out or is to carry out work activities listed above with the plant, structure or substance. All PCBUs must involve their workers in workplace health and safety. A safe workplace is more easily achieved when everyone involved in the work communicates with each other to identify hazards and risks, talks about any health and safety concerns and works together to find solutions.

Workers can also be represented by unions, community or church leaders, lawyers, respected members of ethnic communities, or people working on specific projects.

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Risks to health and safety arise from people being exposed to hazards. A hazard is anything that can cause harm. Before deciding how to manage work risks PCBUs should think about risks more broadly across the work being conducted and the contributing factors. Risks must be eliminated so far as is reasonably practicable.

If a risk cannot be eliminated, it must be minimised so far as is reasonably practicable. PCBUs must take these steps to the extent within their ability to influence and control the matter to which the risks relate. The processes or equipment put in place to eliminate or minimise risk are called control measures. For minimising risk, if the risk is well-known and if there are commonly accepted ways to manage it, these control measures should usually be used. PCBUs with overlapping duties must, so far as is reasonably practicable, work together to manage work risks see section 3.

PCBUs must, so far as is reasonably practicable, engage with their workers when managing work risks see section 3.

PCBUs must, so far as is reasonably practicable, consult, co-operate and co-ordinate activities with all other PCBUs who have health and safety duties in relation to the same matter overlapping duties. Consultation will help to avoid unnecessary duplication of effort eg when providing welfare or first aid facilities. Consultation will help to prevent any gaps in managing health and safety risks. It can help PCBUs reach a common understanding and establish clear roles, responsibilities and actions.

This can occur where there are multiple PCBUs at the same location. Common examples of this are construction sites, shopping centres and multi-tenanted buildings. However, PCBUs do not need to share a workplace to have overlapping duties such as in contracting chains eg forestry work.

PCBUs with overlapping duties must so far as is reasonably practicable consult, co-operate and co-ordinate activities with other PCBUs so that they can all meet their joint responsibilities. However, these PCBUs still retain the responsibility to meet their duties.

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The PCBUs should also monitor each other to ensure everyone is doing what they agreed. The extent of the duty to manage risk depends on the ability of each PCBU to influence and control the matter. This will depend on what ability the PCBU has to influence and control the health and safety matter ie the more influence and control a PCBU has over a health and safety matter, the more responsibility it is likely to have.

A PCBU with a higher level of influence and control and with the greatest share of the responsibilities will usually be in the best position to manage the associated risks. A PCBU with less control or influence may fulfil their responsibilities by making arrangements with the PCBU with the higher level of influence and control. This means that the PCBU with the most financial resources does not automatically have most of the responsibilities.

Consultation can be as simple as exchanging important health and safety information about the following. What work activities will each PCBU carry out ie what will each PCBU do, how will they do it, when will they do it, where will it be done, what plant or substances may be used? What does each PCBU know about the health and safety risks associated with a work activity they carry out?

How will each PCBU manage eliminate or minimise risks associated with a work activity they carry out? How will the PCBUs co-ordinate their emergency procedures including who will notify the regulator when a notifiable event occurs? What further consultation or communication may be required to monitor health and safety, or identify changes in the work or environment?

A finance company leases a multi-storey office block from a building owner. Several lifts operate in the building. The building owner contracts a company the maintenance contractor to maintain and repair the lifts. The finance company is a PCBU and has health and safety duties towards its workers and clients visiting its offices. The building owner is a PCBU who manages and controls the building and has a duty to ensure people can safely enter and exit the building, and that the building is without risk to people.

The maintenance contractor is a PCBU and has health and safety duties towards its workers and other people. The finance company consults the building owner to find out what arrangements are in place for maintaining plant, such as air-conditioning systems and lifts. Before maintenance is carried out on the lifts, the building owner consults the maintenance contractor and the finance company. This is so that all PCBUs know about the work and what they each need to do to ensure the safety of people in the building. These tasks include identifying the best time for the work to be done, how the work area will be barricaded, and what information the finance company will need to give to its workers and clients.

As the work proceeds, the finance company tells the building owner and the maintenance contractor about any concerns or incidents, so they can review them and make any changes needed. The following week the finance company became aware that the maintenance contractor had not fixed a faulty barricade they had been told about.

Hospital transfers and the new Medicare rules…

As this faulty barricade could potentially harm clients, the finance company moved all client meetings to the ground floor until this was fixed. Workers were notified of the faulty barrier and told to use the alternative lifts at the rear of the building. This part explains when the regulator needs to be notified about notifiable events, and how PCBUs should do this. It also explains about authorisations and other notifications required. The regulator must be told about notifiable events that arise from work.

In most cases, it will be WorkSafe. The regulator must be informed of all notifiable events. This notification allows the regulator to investigate or follow up on significant events immediately. A notifiable incident is an unplanned or uncontrolled incident in relation to a workplace that exposes the health and safety of workers or others to a serious risk arising from immediate or imminent exposure to:. Notifiable incidents do not include controlled activities that form part of the business or undertaking eg the controlled release of water from a dam.

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The PCBU who manages or controls the workplace must take all reasonable steps to ensure the site of a notifiable event is not disturbed until authorised by an Inspector ie an Inspector gives permission for normal work to resume at the site of a notifiable event [1]. Regulations can also exclude particular sites from the requirement to preserve sites in particular circumstances note : there are none at present. Work can continue in other parts of the workplace. The most important thing is preventing further harm.

Bill is a farm worker. His jacket becomes entangled in a spinning shaft on a harvester, and in trying to free himself he crushes his hand. The rest of the set-up needs to be left as it is until an Inspector releases the scene. Any work being carried out nearby that could interfere with the incident scene is stopped.

A PCBU must ensure the regulator is notified as soon as possible after it becomes aware of a notifiable event arising out of the conduct of the business or undertaking. This notification must be done even if emergency services attend. Only one notification is required for each notifiable event.

However, all PCBUs are responsible for ensuring a notification is made. The regulator must be notified by the fastest means possible given the circumstances. WorkSafe can be notified as follows. The person giving the notification must provide the details about the incident as requested by the regulator. The PCBU must keep records of notifiable events for at least five years from the date the regulator was notified about the event. Although HSWA does not explicitly state that PCBUs must investigate notifiable events [2] , such investigations form part of good practice to identify and manage work risk.

Construction Management Limited CM Ltd is a large company that oversees several construction projects.

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Clinical notes play an important role in providing quality care and in maintaining the integrity of the therapeutic relationship. Many clinicians request guidance in. Find helpful customer reviews and review ratings for Adventures in Clinical Record Keeping: An Easy Guide to Progress Notes at Read honest .

It engages ABC Ltd to manage one of its sites. ABC Ltd engages a contractor, Sue, to do plumbing work. Sue has an employee, Jim, working for her. Jim amputates his finger on an angle grinder and is taken to hospital. As required, the accident site was preserved and WorkSafe was notified.

They identified what caused it and, so far as was reasonably practicable, revised existing control measures and put in place new ones to prevent it happening again. Certain workplaces, work activities, plant or substances must have appropriate approvals authorisations. Authorisations are licences, permits, consents, certificates, registrations or other authorities described in health and safety regulations, and must be obtained before relevant work begins.

Authorisations may be given by WorkSafe, another regulator or a third party authorised to do this. Only prescribed workplaces, plant or substances, or work requires authorisation. Sometimes the authorisation is in the form of certain qualifications, experience or supervision required by workers to carry out the work.

WorkSafe needs to be told within specified times before certain work activities are carried out such as certain asbestos removal work. Organisations can have more than one officer. Each officer has a duty — it is not a joint duty. People who provide health and safety or other advice, or make recommendations to senior leadership are not officers solely on this basis.

Some examples of people who are not officers unless they also fall into one of the officer categories described above include:. Together they make decisions about strategies and policies such as spending and investment. They determine the annual health and safety budget and sign off large purchases of safety equipment. Bill, Anne and Alan are all officers because they are directors of the Endless Aisles Supermarkets business. Ruth is the Chief Executive Officer. She is responsible for managing all three Endless Aisles supermarkets.

She makes decisions about resource allocation, spending, store and people management. Ruth is an officer because she exercises significant influence over the management of the business. Troy is the Quality and Compliance Manager middle management. He is responsible for co-ordinating health and safety and quality management.

He organises safety training, collects incident reports and statistics, and conducts safety audits.