Documentation and records management

Why is it important for service providers to document?

• Shelters and shelter services receive highly personal information about women and girls seeking assistance and their family members. It is important to establish systems for managing this information to ensure women’s safety and confidentiality are maintained throughout their time at the shelter and in regards to any service they receive.
• Women accessing shelters may want to have certain information shared (such as evidence or testimonies they have provided and want to use in a legal case), and other information to be kept confidential (e.g. identity documents or medical records), which requires systematic information and records management processes.
• Sound documentation and records management allow shelters to meet ethical responsibilities to women accessing services as well as organizational requirements related to information gathered. Sound management practices generally involve:
  • integrating important service principles, such as respect, gender equity, and empowerment in day-to-day practices;
  • managing requests for information about women in an accountable manner that aligns with their interests;
  • complying with legislation related to privacy and information, which dictates how records may or may not be gathered, used and destroyed;
  • guiding staff in their responsibilities related to records documentation and management;
  • supporting effective safety planning, service planning and implementation, as well as staff supervision; and
  • assisting management and governing bodies when faced with legal liability for staff actions.
• Proper records management can help to increase women’s trust in the shelter’s services (for example, by demonstrating that their confidentiality and decisions are central), and can encourage survivors to utilize their own records in the process of overcoming their experiences of violence, which can help promote women’s  interests, needs and self-determination.

General considerations

• Documentation and management of records refers to the process of gathering, documenting, organizing, retaining, using, sharing and destroying written information provided by and about women accessing services.
• Records management systems should:
  • Ensure that the content and use of records maintains the confidentiality of personal information.
  • Base the scope of information to be gathered and used on the needs and interests of women and girls at the shelter.
  • Be informed by locally-relevant privacy legislation in order to cover the full range of accountability requirements of the organization.
• Gather only information absolutely necessary to effectively plan, support or deliver the specific service requested, which should be used to:
  • Establish whether the woman is safe and identify her security needs.
  • Determine her eligibility for services (such as welfare payments/ food assistance, free child care, subsidized housing or health care, etc.).
  • Determine whether legal proceedings are in progress or anticipated.
  • Determine the relevance of services based on a woman's interest and expressed needs at the time.
  • Assist in developing a service plan, including consideration of specific needs.
  • Document when and how services are provided to the woman.
  • Gather data and information to assist with understanding the effectiveness and impact of services (Monitoring and Evaluation).
• Enable staff to review the effectiveness of services provided, and to respond accordingly by collecting and analyzing information regarding activities and services from:
  • Screening processes and forms. 
  • Assessment forms and tools. 
  • Service and follow-up planning documents.
  • Plans for transitioning out of the shelter.
• Establish limits on how information will be collected, used and retained (unless a client later consents to the use of information for additional purposes).
• The documentation and records management process should:
  • Ensure that exceptions to the confidentiality of information are explained to women and girls before any information is documented.
  • Provide women with an explanation of the information needed for them to provide informed consent, including the range of benefits and risks involved in sharing their personal information.
  • Involve sharing of information about the services being provided to women and girls.

• Organizations should have a written policy regarding the retention and disposal of records, which can help communicate clearly to staff and women accessing services about the rationale and duration in which records will be retained. The policy should be developed with consideration to the following:
  • Service providers should be able to justify the length of time records are retained. Information should be kept long enough to ensure it is available to support the potential needs of women (e.g. covering the statute of limitations or duration in which a woman may file a case, even after leaving the shelter), but not longer.
  • Shelters may choose to retain records for several years in order to provide women with their personal information when it may be helpful later (i.e. to recall/process details of their physical, emotional or therapeutic experience or to engage in legal proceedings).
  • Decisions about the duration of records retention may be determined and explained by space and financial limitations to providing secure storage, accepted practices in the field or by the agreement of individual clients served by the programme.
  • Ensuring all information is made available to the survivor upon her request.

(Records Management, Ruebsaat, 2006)