The Community Counseling Clinic (CCC) maintains a strict 24-hr policy on all clinical documentation. We ask that all counselors complete their Clinical Case Notes and any additional documentation within 24 hours of their session. CCC counselors must document all client contact including phone calls, voice mails, and counseling sessions. Cancelled and missed appointments must also be documented with a progress note. Phone messages left with the clinic must also be documented through an Ancillary Note.
All documentation is now done through Titanium Schedule. Please note that Titanium can only be accessed through Clinic computers while on campus, unless remote desktop access has been coordinated with the COE IT Team (necessary during virtual-only services).
CCC counselors are advised that clients have right of access. Clients have the right to request and access their protected health information and clinical record (as per HIPAA) at any time. Access requests must be coordinated in consultation with the Practicum Instructor and Clinic Director.
Clinical Case Notes:
Notes must be completed after each clinical contact with clients.
Notes for the CCC follow the D.A.P. (Data Assessment Plan) format for documentation.
Notes must be written in clinically appropriate language and be free of spelling or grammatical errors.
Notes must be concise and avoid clinical jargon, CCC counselors should avoid abbreviations not easily understood.
CCC counselors in practicum must complete notes before leaving practicum on the day of the session - unless specifically stipulated by the Practicum Instructor.
All Clinical Case Notes must be signed by the Practicum Instructor prior to the end of the overall Practicum experience. We understand that some Practicum Instructors will have their own processes, which may delay final signature. Please do your best not sign out of Titanium or close your laptop prior to confirming that your supervisor has signed all of your notes.
Ancillary Notes:
Ancillary Notes must be completed after each non-clinical contact with clients, these include phone calls, voicemails, emails, and non-therapeutic communication.
Ancillary Notes should include concise and factual description of contact.
CCC counselors in practicum must complete ancillary notes before leaving practicum or on the day of contact.
Notes must be written in clinically appropriate language and be free of spelling or grammatical errors.