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This policies and procedures guide how we work and provide a road map of how things run at Calm and Connected. It is important that these are followed to ensure the safety of collegues and clients. The information in these policies are informed by laws and requirements of our APRHA registration.

Documentation Policy

Overview 

OT students to complete the following documentation for each child they work with:

Progress Notes

Please complete progress notes on Cliniko under the child’s folder within 24 hours of the event. Events may include:

When documenting assessments, if details are adequately covered in assessment forms which have been uploaded to Echidna, you can write a sentence to the effect of “Please refer to _____ in attachments for further information”

All notes are automatically dated in Echidna at the time of completion. In addition for each note, please include: Your name, Occupational Therapy Student

Progress notes are to be written using SOAP formatting:

Goal Setting 

Individual Clients: Goal setting is to be completed with both the child’s teacher and parents where possible. It is recommended that a maximum of 2 goals are set with children to allow for targeted intervention. More goals can be set once these initial goals have been achieved. 

Groups, presentations and projects: Goal setting is to be completed with teachers, staff and OT students involved.

Goals are to be written using the SMART (Meyer, 2003) goal format and entered into the Goal tab in Echidna:

Rating Goals

All goals are to be rated using COPM rating scales, using a number scale from one to 10. Parents, teachers and OT students are to choose one number per category. It is best to try and complete these quickly to capture your initial/’gut’ feeling. 

Collecting this data will allow us to provide this information to the parents or school for their reporting back to the education department. It also good practice to monitor therapy and determine if intervention has been successful. This is a great opportunity to advocate for the role Occupational Therapists can play in schools, at home and in the community. 

Please complete this for all individual clients, small groups and whole class groups you work with when discussing goals with teachers and parents. 

Reports

Some points to consider when completing reports:

All reports must be read and signed by your supervisor. Do not give reports to parents or teachers without your supervisor reading them and singing them off first. You may provide your Calm and Connected email as a contact detail on reports but do not put your phone number on this, please put the teacher as the point of contact for the parents. 

Initial Summary Report

You are to complete an Initial Summary Report for all children you work with using the Initial Summary Report Template found in the templates section. It is recommended to get started on these reports early, just start adding information as you learn about the child. You will be surprised by how much you do know about the client after just one interaction. Writing reports is a great way to formalise your initial findings and shape your clinical reasoning so that you are ready to start intervention phase. 

Feedback and editing

All initial summary reports are to be completed by Tuesday of Week 3 of placement.

Final Summary Report

You are to complete a Final Summary Report for all children you work with using the Final Summary Report Template found in this portal. This report forms the basis of handover, what the child has achieved and what further support they need. It is a great opportunity to showcase all that you have learnt about the child and strategies that you have learnt that worked well. Really think about all those small adjustments that you may automatically make when working with the child that lead to success that may differ from how a teacher/parent might approach the same things  i.e how instructions were given, the environment set up, the order of activities.

Feedback and editing

All final summary reports are to be completed by Thursday of week 8 of placement.

Home Visiting Policy

When home visiting it is essential you look after your own safety and health and be aware of dangers and risks associated with home visiting. The following issues related to home visiting have been considered by Calm and Connected staff. You are strongly encouraged to feedback any concerns you may have about safety or if any changes occur in the environment.

Prior to appointment

During the appointment

Confidentiality

Principles

Confidentiality of all client details, records, circumstances and information is to be strictly maintained at all times during fieldwork. Students must agree to abide by these confidentiality requirements when they sign the Calm and Connected Confidentiality Agreement prior to commencing fieldwork. 

The following issues related to confidentiality must be considered but are not limited to:

Calm and Connected policies and guidelines

Calm and Connected maintains the tenets of professional confidentiality and observes the requirements of the Privacy Act. All other relevant policies can be found on Google Sites. 

Privacy policy

According to the Federal Privacy Act 1988, Calm and Connected is required to maintain confidential records according to standard practices. To that end, the Calm and Connected has developed a confidentiality policy, which contains the following key provisions:

Record keeping

Each Service maintains records on all clients in keeping with normal standards of professional accountability. These records are not accessible to any person outside the particular Service. 

Release of information

Information about a client may be released to parties outside a Service only with the explicit consent of the client. Release of information will normally require a written consent to disclosure signed by the client. Verbal agreement may be accepted only when both client and staff member agree that the circumstances do not require the formality of a written agreement.

Limits of confidentiality

Information may be disclosed without the consent of a client when:

Legal obligation includes such circumstances as a court subpoena, a valid search warrant, or such other legislated requirements that may be in force at any given time.

Sharing Information

In this age of technology, it has become increasingly easy and instantaneous to share information regarding life experiences.  However, with regard to your fieldwork placement, we request that you DO NOT share any information that compromises confidentiality of clients- in any way, including verbally, in writing or on social media.

Any social networking or other sharing that you do regarding your fieldwork placement  MUST NOT include:

It does not matter whether a social networking circle is “private” or “closed,” this information CANNOT be shared.  In some cases we have signed releases for certain privileges regarding photo or video usage for clients, but it does not include identifying clients on an internet site of any type.  Please be sensitive to the desires of parents, families and the school in this regard and help us keep this placement and relationship with the school and families both professional and confidential.

If in doubt- don’t do it!

Sick Leave and TOIL

Sick Leave

While on placement, if you are unwell and cannot attend placement on that day, please phone your supervisor. If they do not answer their phone, please send them a text message and try to call back later until you have reached them. Please provide medical certificates and inform the OT school as as per their Fieldwork Guidelines. 

If you need to attend a personal appointment, please advise your supervisor and ensure your timetable has been adjusted, and teachers/families/students informed if you are unable to make the session. At this time, please re-schedule this appointment for another day as close to the date as possible. 

As per your Fieldwork Manual, if you miss a substantial amount of placement, this time may potentially be re-arranged or another placement organised.

TOIL – Time in lou 

If you attend sessions out of hours or attend Therapy Intensive Camps then you will accrue TOIL. This means that you can take this time off at a later date. TOIL is not accrued for documentation and preparation – only face to face client sessions. Discuss when you would like to take your TOIL with your supervisor, they will ensure that the time off doesn’t impact your client services. Block out this time as an unavailable block in your calendar once it is approved.

Occupational Health and Safety

Risk Assessment Documentation

With your supervisor you will complete a Risk Assessment Form if visiting a new client’s home, to be upload to the clients file in Cliniko under ‘Attachments’. This can be found in the ‘documentation’ folder on Google Drive.

Managing Placement 

We want to make sure that enjoy your placement and learn a lot from the experience. It is common to feel overwhelmed at the beginning coming into a new work place and clinical area. So if you feel overwhelmed or that you are not coping with placement, please tell your supervisor and arrange a time to talk to them about so they can offer support, make adjustments and plans to best support you and your learning. 

Working with children can often be challenging and many issues can arise from sessions. It is important to debrief with your supervisor and/or other students frequently, especially if there has been an event or situation of concern to you, or that you feel you have been thinking about something a lot. Looking after yourself on placement is very important and we can support you in identifying strategies that help you. 

Managing Disclosures

Many of the children we work with have experienced trauma. Sometimes this is disclosed to us by a caregiver or teacher so are aware, and other times a child may disclose something that has occurred to them during a session. To manage this:

Hearing a disclosure from a child can be distressing and it is common to experience symptoms of shock. Symptoms can occur hours after you have gone home, so be prepared for any unusual feelings such as shaking, crying, feelings of hopelessness. It is important to think of your self care during this time and what will assist you to feel better; quiet time, being with friends. Please talk to your supervisor or the counselling services at Curtin University if you experience this normal reaction. 

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