1.7.1 Service Records
Volume 1: |
Agency Standards |
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Chapter 7: |
Service Administration |
Section 1: |
Service Records |
Approved: |
2024/10/01 |
This section pertains to records of services provided to individuals and families under The Child and Family Services Act and The Adoption Act. It applies to child and family services agencies and licensed adoption agencies.
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The Child and Family Services Act
Section 1 of The Child and Family Services Act (the Act) defines record as a record of information in any form.
Section 19.1(1) requires the director to establish and maintain the child abuse registry. Section 19.3 contains registry provisions relating to confidentiality, access, objections and Section 19.4 removal of information.
Section 76 pertains to confidentiality of and access to records under the Act. Subsection 76(3) states that a record created under the Act is confidential and lists the exceptions to this rule. Subsection 76(14) has strict rules regarding closed child-in-care files when the child turns 18 years old. The remaining subsections contain provisions relating to access by the subject of a record, director’s reviews when access is denied, and retention, storage and destruction of records.
Section 86.1 states that if a provision in this Act is inconsistent or in conflict with a provision in The Freedom of Information and Protection of Privacy Act (FIPPA), the provisions of this Act prevail.
Part 4 of the Child and Family Services Regulation contains provisions relating to agency records. Section 9 pertains to security safeguards. Sections 10 and 11 give the director authority to establish procedures relating to the retention and destruction of records under the Act and sets out retention requirements.
The Adoption Act
Section 1 of The Adoption Act defines central adoption registry, post-adoption registry and record. The definition of record is the same as that in the Act.
Part 4 of the Act contains provisions relating to confidentiality, disclosure and the post-adoption registry. Section 99 states that if a provision in this Part is inconsistent or in conflict with a provision in FIPPA or The Protecting and Supporting Children (Information Sharing) Act the provisions of this Part prevails. Section 103 pertains to confidentiality and storage of adoption records. Section 104 states when identifying and non-identifying information can be disclosed. Section 105 provides for disclosure for research purposes.
Part 4 of the Adoption Regulation pertains to adoption records. Section 47 states what records are to be kept. Section 48 covers closed records. Section 49 deals with security safeguards. Section 50 covers maintenance and destruction of records.
The Child and Family Services Authorities Act
Section 1 of the Child and Family Services Authorities Regulation defines agency service record as a record in the custody or under the control of an agency that relates to providing child and family services to a person or family.
The Freedom of Information and Protection of Privacy Act
The Freedom of Information and Protection of Privacy Act (FIPPA) applies to child and family services authorities and agencies with respect to records other than those created under The Child and Family Services Act and The Adoption Act. It does not apply to licensed adoption agencies. Relevant definitions in section 1 are government agency, personal health information, personal information and public body. Child and family services agencies and authorities are listed in regulation as government agencies.
Schedule B in the Access and Privacy Regulation lists authorities and agencies as government agencies.
The Personal Health Information Act
The Personal Health Information Act (PHIA) applies to all citizens and organizations of Manitoba. Relevant definitions in section 1 include personal health information, public body and trustee. Personal health information includes a person’s personal health identification number (PHIN). A public body has the same meaning as in FIPPA. A trustee is defined as a health professional, health care facility, public body, or health services agency that collects or maintains personal health information.
Section 4 addresses the relationship of PHIA to other provincial statutes. Part 2 pertains to a person’s right to access personal health information. Protection of privacy provisions in Part 3 cover restrictions on collection and retention of information, security safeguards restrictions on use and disclosure of information, and miscellaneous requirements.
Section 4 of the Personal Health Information Regulation contains additional restrictions and precautions required by a trustee with respect to personal health information. Section 5 requires a trustee to determine the personal health information that each employee and agent is authorized to access. Section 6 requires trustees to provide orientation and training for employees and agents. Section 7 states that employees and agents must sign a pledge of confidentiality.
The Mental Health Act
The Mental Health Act (MHA) prevails over all other provincial statutes. Section 1 defines a clinical record as a clinical record compiled and maintained in a facility respecting a patient, and includes a part of a clinical record and any document prepared for the purpose of a disposition under Part XX.1 of the Criminal Code (Canada). A facility refers to a place designated in the regulations as a facility for the observation, assessment, diagnosis and treatment of persons who suffer from mental disorders. Section 36 pertains to confidentiality of clinical records.
The Archives and Recordkeeping Act (ARA)
The Archives and Recordkeeping Act enables the long term preservation of records with significance and promotes good recordkeeping practices to ensure accountability to the public. The Act applies to local authorities as well as government departments and agencies.
Under section 13, the archivist may enter into an agreement with a local authority with respect to its records. The Archives and Recordkeeping Regulation designates authorities under The Child and Family Services Authorities Act as local authorities.
Under section 14, the archivist may enter into an agreement with a child and family services agency with respect to the retention, storage and destruction of agency records under the Act and The Adoption Act.
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Terminology
The following terms apply to service records created by child and family services agencies and, with respect to adoption services, to licensed adoption agencies:
Adoption Record – a record pertaining to the granting of an order of adoption in the custody or control of the director, a child and family services authority, a child and family services agency or an licensed adoption agency (section 1 of the Adoption Regulation).
Agency Service Record – a service record in the custody or under the control of a child and family services agency or licensed adoption agency that relates to providing services to a person or family. This definition includes an agency service record as defined in section 1 of the Child and Family Services Authorities Regulation, an agency record as defined in section 8 of the Child and Family Services Regulation, and an adoption record in the custody or under the control of an agency.
Case – in general terms, a set of circumstances or conditions requiring a service or intervention. In child and family services, a case is a type or category of service provided to a person or family (Case Categories).
Case Record – all records and documents relating to a case. This broad definition includes information collected and recorded at intake. In CFSIS, a case record refers to case information as distinct from person information. A case record is always attached to a person record. In this section, case record has the same meaning as service record.
File – has the same meaning as record.
Person Record – a CFSIS record containing information about persons involved in a case.
Record – a record as defined in section 1 of the Act and section 1 of The Adoption Act.
Service Record – a record of services provided to a person or family under the Act or The Adoption Act. In this section, service record has the same meaning as case record.
Minimum Requirements
Agencies are expected to use recordkeeping systems and processes that facilitate compliance with legislation and regulations. This policy applies to both paper and electronic records. Agency responsibilities include:
- record management practices that facilitate the case management process
- compliance with confidentiality and access requirements in section 76 of the Act and sections 103 and 104 of The Adoption Act
- Record storage and security safeguards in compliance with sections 9 and 10 of the Child and Family Services Regulation and sections 47 to 49 of the Adoption Regulation.
- Record retention practices in compliance with sections 10 and 11 of the Child and Family Services Regulation and section 50 of the Adoption Regulation, and for service records with agency records schedules.
- Record keeping practices will ensure that the records will remain accessible, have integrity, and be reliable for their full retention period. Introduction to Records and Information Management is a helpful resource.
Case Categories
Agencies are required to maintain records by case category regarding services they provide to individuals, families and children under the Act and The Adoption Act. This policy applies to both paper and electronic records. The definitions of the following case categories can be found on CFSIS (Forms/CFSA Help Desk/“Case Category List”):
- Adoptive Applicant (AdA)
- Child Service Case (CS)
- Child Service Case – Supervision (Sup)
- Expectant Parents Services (EPS) Services
- Foster Care Management (FCM)
- Incidental Service Record
- Post-Adoption (PA)
- Protection (Prt)
- Voluntary Family Services (VFS)
Confidentiality and Access
Agencies are expected to have written policies regarding confidentiality and access provisions in section 76 of the Act and sections 103 to 105 of The Adoption Act. These policies should be available or accessible to board members, management, staff, committee members and others providing work or services for an agency.
Service Record Disclosure Policies – In the previous paragraph, the statutory provisions require agencies to use discretion regarding disclosure of information from a service record either verbally or through copies or written summaries. The policy should be in compliance with the Protecting and Supporting Children (Information Sharing) Act.
Service Record Access Policies – Agency policies must facilitate a person’s right to examine or obtain a copy of their service record or a summary of the record under section 76 of the Act.
Service Record Retention
Records generated in the course of providing services under the Act and The Adoption Act have significant archival value from various perspectives including:
- effective service delivery
- operation of provincial registries
- statutory access and disclosure provisions
- inquest, inquiries, lawsuits and criminal prosecution
Agency service records are governed by records schedules, which authorize the retention and disposition of the records and serve as a plan for managing the records through their life cycle. The branch and the Government Records Office, Archives of Manitoba, developed the schedules in consultation with agencies. They were approved and distributed to all agencies in 2002. They state how long the records must be retained, when they should be sent to the Government Records Centre for storage, and, for those records which will be kept permanently, when they are to be transferred to Archives.
Agencies are required to maintain a complete set of records schedules. Copies of these schedules are available on the Manitoba government intranet at Families CYS Records Schedules (mbgov.ca) or through the following departmental contact:
Records Management Officer
Department of Families
Financial and Administrative Services
200-114 Garry Street, Winnipeg, Manitoba, R3C 4V4
Phone: (204) 945-0713
Fax: (204) 945-2760
Email: FAMArchives@gov.mb.caAgencies should also refer to the following procedures and forms needed to transfer and retrieve records from the Government Records Centre:
Procedures
GRO 2, Transferring Government Records
GRO 3 Retrieving Government Records -
Record Management Practices
- Agency Service Record Policies – An agency has written policies for the management of service records that are:
- consistent with requirements in legislation and policy outlined in this section
- for a child and family services agency, consistent with records management practices required by its mandating authority
- distributed or available to board members, managers, supervisors, workers, committee members and others who have access to service records
- Recording Incidental Service Contacts – General enquiries regarding agency services and requests for services more appropriately provided by another human service organization are recorded as incidental service. When using the Child and Family Services Application, the intake worker opens a person record and records the required information as an intake note, but does not open a case record.
- Content of Intake Records – At minimum, agency intake records contain the following information, in a hard copy, paper file:
- for a child and family services agency, personal and case information gathered through the use of the Intake Module
- for a licensed adoption agency, personal and case information required to make a decision whether to open a file on a birth parent or adoptive applicant
- case notes by date recorded relating to referrals, client and collateral contacts, intake assessments, services provided and intake decisions
- relevant correspondence, including emails (printed), emails containing correspondence to set up meetings or with information not relevant to case management do not need to be printed
- names of the intake worker(s) and supervisor(s) involved in the case
- Content of Records Opened for Ongoing Service – At minimum, records of cases opened for ongoing service contain the following information in a hard copy, paper file:
- personal and case information recorded at intake
- applicable initial and updated agency assessments and reports such as family assessments, child assessments, court reports and home studies
- signed copies of applicable forms prescribed by regulation or required by the director, a child and family services authority or the agency
- third-party information such as correspondence, reports and assessments received from individuals and organizations (for example, medical reports, psychological assessments, school reports and police referrals)
- copies of agency correspondence
- any non-textual information or records such as photographs, audio or video tapes, art work, and references to any digital information
- case notes by date recorded relating to further information obtained or received, client and collateral contacts, services provided and case decisions
- relevant correspondence, including emails (printed), names of the case manager and supervisor and of service providers involved in the case
- Current Photographs of All Children in Care – An agency ensures that current digital photographs of all children in care are available and stored on the Child Service Case on CFSIS and prints of the photo stored on the child’s paper file and given to the child’s caregiver. The photo should be taken as soon as practical and within one month from the date the child comes into care and updated annually.
- Personal Health and Mental Health Information – An agency collects personal health and mental health information only when necessary for the provision of services under the Act or The Adoption Act. This information is recorded or stored in the service record of the person or family to which it applies. Services that may require the collection and use of person and mental health information include child protection investigations, children in care, and foster parent and adoptive parent applications.
- Duplicate Information and Records – An agency does not duplicate information or documentation from a service record for internal agency operations except when necessary to:
- create a central record or registry of intake
- facilitate the delivery of services through a sub-office or between agency service units
- create a back-up copy in the event agency service records are lost or destroyed through events such as computer failure, fire or flooding
Child Protection and Voluntary Family Services Cases – A record is opened as a protection (Prt) case when a child is in need of protection as defined in section 17 and an investigation is required under subsection 18.4(1) of The Child and Family Services Act.
If there are no longer child protection concerns and the family has requested ongoing services, the case category is changed to VFS. The PRT file is closed and a VFS file is opened. The reasons for and dates of case category changes are recorded.
If a voluntary family services (VFS) case is changed to a protection (Prt) case, the agency informs the person or family pursuant to subsection 76(13) of the Act. The VFS file is closed and a new PRT file is opened.- Transfer and Closing Summaries – When recommending that a service record be transferred or closed, an intake worker or case manager, completes a closing summary and ensures that all legal and administrative documents are included in the paper file. The closing summary includes the following information:
- persons in the case
- reasons for opening the case
- services provided to the person or family
- service outcomes
- reasons for transferring or closing the case
- references to any digital records that could not be printed (i.e. audio, video files) and their addition to CFIS or other location
- date record closed
- Review of Service Records by Supervisors – When conducting case reviews, agency supervisors ensure that information and documentation is stored or filed in the appropriate case record.
- Disclosing Information from a Service Record – No information is disclosed from an agency service record without the written consent of the subject of the record except:
- as provided for under section 76 of the Act and section 104 of The Adoption Act to offices that have statutory authority to access or obtain copies of records including the Manitoba Ombudsman, Chief Medical Officer, Manitoba
- Advocate for Children and Youth, the Director of Child and Family Services and an agency’s mandating authority in accordance with confidentiality and access policy in this section
- Recording Requests for Access to Service Records – A worker or supervisor, on receiving a request for access to a record by the subject of the record or, in the case a voluntary placement agreement or voluntary care agreement, by a parent or guardian, records the nature and date of the request and what action was taken in response to the request.
- Complaints Relating to Confidentiality and Access – An agency’s process for reviewing complaints regarding the disclosure of information from a record or denial of access to a record are consistent with the requirements in Section 1.7.3, Complaint Review Process.
The province is responsible for creating back-up copies of computer records created through the Intake Module and the Child and Family Services Information System.
Record Storage and Security
- Record Storage – Agency policies and procedures for storage of service records include reasonable administrative, technical and physical safeguards that ensure the confidentiality, security, accuracy and integrity of the information required. These safeguards are in compliance with sections 9 and 10 of the Child and Family Services Regulation and sections 47 to 49 of the Adoption Regulation.
- Authorized Access to Records – Agency policies and procedures clearly state who within the agency is authorized to access service records and the process whereby a person is authorized to do so. These statements are in compliance with sections 9 and 10 of the Child and Family Services Regulation and sections 47 to 49 of the Adoption Regulation.
- Closed Child-in-Care Records – Agency policies and procedures for storage of and access to closed agency child-in-care records are in compliance with requirements under subsection 76(14) of the Act and subsection 9(2) of the Child and Family Services Regulation.
- Closed Adoption Records – Agency policies and procedures for storage of and access to closed agency adoption records are in compliance with subsection 103(2) of The Adoption Act and section 48 of the Adoption Regulation.
Records Schedules
- Designated Persons to Administer Schedules – An agency ensures that appropriate staff are assigned responsibility for administering provincial records schedules in each office of the agency and to coordinate transferring records to or retrieving them from the Government Records Centre.
- Regular Review of Records – The designated persons in Standard 1, schedule a review of all service records at least once a year to determine which records should be transferred to the Government Records Centre. These reviews are done in collaboration with service delivery supervisors who decide which records should be sent to the centre.