Documentation Tips and Guidelines

There is no way to give one absolute set of guidelines for documentation in a school counseling setting. Each district and each school may have its own policies, based on the needs of its students or community. Having said that, here are some things to consider.

Basic Considerations:

First, check with your supervisor to find out if there is a specific procedure or set of guidelines already in place. If there is, please use it, but you may also want to consider the following items so you can be as efficient and effective as possible, and so you can be prepared in case legal or ethical dilemmas arise.

Unlike social workers and clinical counselors, whose documentation is considered “case notes” and may be read by various people, school counselors often keep “anecdotal notes,” which are separate from the student’s permanent record, and kept in folders in each counselor’s private filing cabinet. I would encourage you to ask your supervisor in advance who has access to your files and who is allowed to see them upon request.

For instance, if a parent asks to see your notes, are you allowed (or required) to grant that request? Does your administration have the right to access your files? It’s important to know this ahead of time.

Anecdotal Notes:

If your records are considered “anecdotal notes,” then they are your personal property and are not to be shown to anyone, under any circumstances. When I worked in the public schools, I was taught that if I physically show my notes to one other person, the notes become public property and can no longer be considered confidential, so anyone can see them – they could even be printed in the newspaper. Even if I was subpoenaed, I was instructed to take my notes with me and read from them in court, but not to visually show them or turn them over to anyone.

If you are keeping anecdotal notes, you may want to consider including a simple, one-page summary of your time spent with a particular student, which you could refer to, or even make copies of, if a parent or your administrator requested the information. A sample of a summary like this is included later in this article.

When To Get More Detailed:

If you are keeping anecdotal records, there are certain situations where you will want to take more detailed notes, usually on a separate page from your basic summary. These are typically the times when student safety is in question, or there may be legal involvement, and you are required to notify parents, administration, the school nurse, the police, or CPS about something a student has told you. These situations will most often include the following:

~ Any question of a student’s safety being at risk

~ Self-harm (such as cutting, eating disorders, etc.) or suicide attempt or plan

~ Threats of violence or harm to others, particularly at school

~ Drugs or weapons on campus; some off-campus drug use

~ Known or suspected abuse or neglect

~ Suspected or confirmed pregnancy

~ Sexual activity between minors and adults (even with consent)

~ Harassment, bullying, or discrimination

~ Cheating, stealing, etc., particularly at school

~ Custody battles (because of potential legal involvement)

~ Angry or volatile parents in most any situation

~ Any other situation you feel uneasy about – better safe than sorry!

Which Details To Include:

When you do need to get more detailed, here are some things to include in your documentation:

~ The time and date that you spoke with the student

~ Exactly what the student said, in quotes, without paraphrasing or editorializing

~ Interventions that you did with the student at the time (processes you walked them through, worksheets you had them fill out, etc.)

~ Recommendations or suggestions that you made to the student

~ Follow-up calls or conversations you had with anyone else (parents, administrators, police, CPS, etc.) including time and date, who you spoke with, and the content of those conversations, also specifically quoting rather than paraphrasing what the other parties said when it seems significant

~ Any recommendations, referrals or community resources you offered to the parents

~ Any other details you want to have in writing for future reference

Documenting on the Computer:

If you are keeping your anecdotal records on a computer that is owned by the school, which is the case in some districts, please keep in mind that even if your records are considered confidential, they are still part of a bigger network and may be accessed by others. If you want more privacy than that, you may choose at certain times to hand write your notes and keep them in a locked filing cabinet.

Some districts are requiring counselors to do all of their documentation on the school’s shared computer system, where it can be seen by other counselors, administration, and anyone with access to this system. While I believe this is a huge violation of ethics and confidentiality, it is the policy in some schools.

If your school requires this, I strongly encourage you to keep that documentation very general and minimal, and keep more detailed notes in student files, in a locked filing cabinet in your office. Ethically, informing students and parents about this computerized documentation system is important – they have a right to know in advance who will have access to their records.

Documentation at Different Grade Levels:

If you are a high school guidance counselor, you may not be required to keep track of every student you see, or those records may be kept on sign-up sheets in the reception area of the guidance department. If that is the case, the only time you will need to document specific information is when you have an exception to your regular confidentiality guidelines – in other words, if you need to notify parents, administration, or the school nurse about something, or make a CPS or police report.

If you are a school counselor anywhere in the K-8 grade levels, you may be required to keep documentation of every student you see, as well as more specific and detailed notes in situations where safety or legality is a concern. Again, check with your supervisor in advance to see what is expected.

Documentation Options:

If you are required to keep basic documentation of every student you see, whether for statistical purposes or accountability, one of the easiest ways to do this is to use a daily planner or calendar and just write in the names of the students you see each day, along with your other daily information. If you need to keep track of other basic information such as how many students you see from each grade level, or on what subjects, you could make notations on your calendar such as:

Sarah Jones, 6th gr., gossip
Zach Garcia, 8th gr., scheduling
Emily Miller, 4th gr., grief

If you need a basic documentation list of all student you see, which you can then turn in to your supervisor or principal (and you don’t want to make copies of your daily planner, which might contain other information you don’t want made public), you can create a separate form that you can photocopy and turn in periodically.

This also means you can keep the vast majority of your documentation very brief, and save the detailed note-taking for the times it’s actually needed. Please see the example given in the PDF version of this article below as “Record of All Students Seen.”

If you need to create separate folders for some or all of the students you see, I would recommend having one basic documentation sheet for each student that you could photocopy and turn in to a supervisor or administrator if needed, and that you keep additional anecdotal notes on separate pages, also stored in the student’s folder. That way, the basic sheet is your “official documentation” and any additional notes are anecdotal records and are your private property, not to be shared. Please see the example given in the article below as “Individual Student Contact Sheet.”

You may need to document parent contacts as well, and I would certainly recommend it in any case where you are notifying parents about a safety issue or another touchy or controversial issue involving their child. In some schools, you will be asked to keep this as a separate record, and in others, it will be part of your regular daily documentation and can be listed along with student contacts or in your daily planner or calendar. I would suggest keeping track of parent contacts in the student’s individual folder. If you need to make a separate log, please see the example given in the article below as “Parent Contact Log.”

If you are facilitating one or more support groups, you may also want to keep track of the students in your group, group attendance, and what topics or lessons you’ve covered in group. Please see the example given in the article below as “Support Group Log.”

Here is the PDF version of this article, Documentation Tips and Guidelines For School Counselors.

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