SAMPLE POLICY WORK

c. Detailed Policies and Procedures

A. Individual Client Files Individual client files are at the heart of our service delivery. These files must contain all pertinent information about each client to ensure seamless continuity of care, accurate service delivery, and compliance with regulatory requirements. Purpose and Importance: Maintaining comprehensive individual client files ensures that every client receives personalized, consistent, and high-quality care. These files serve as the primary source of clinical data for each client, providing historical information that is critical for decision making, treatment planning, and incident management.

Required Contents of Client Files:

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Assessment Reports: –

Initial assessments, psychological evaluations, functional skills evaluations, and periodic re-assessments.

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Individual Support Plans (ISPs): –

Customized care plans outlining client-specific goals, interventions, support levels, and outcome measures.

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Progress and Service Notes: – Detailed daily logs, progress notes, and incident reports documenting each service interaction and any deviations from the plan. • Medical and Health Records: – Health history, medication administration records (MARs), clinical care notes, and emergency reports. • Correspondence and Consent Forms: – All consent forms, communications with family members or guardians, and feedback from clients. • Regulatory Reports: – Copies of regulatory submissions and internal audit reports concerning the client's care.

Procedural Guidelines:

Creation and Maintenance: – Every new client file is created immediately upon intake in the centralized digital records system. – All initial assessments, consent forms, and baseline data are uploaded and verified by the intake team. 2. Updating Records: – Each client’s record is updated in real time as progress notes, service logs, and new assessments are completed.