1.7.1 Service Records

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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.

Legislation

The Child and Family Services Act
The Adoption Act
The Child and Family Services Authorities Act
The Freedom of Information and Protection of Privacy Act
The Personal Health Information Act
The Mental Health Act
The Archives and Record Keeping Act

The Child and Family Services Act

Section 1 of The Child and Family Services Act defines record as a record of information in any form.

Section 19.1 requires the Director of Child and Family Services (director) to establish and maintain the child abuse registry. Section 19.3 contains registry provisions relating to confidentiality, access, objections and 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 turn 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, 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 Child and Family Services 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 Act is inconsistent or in conflict with a provision in The Freedom of Information and Protection of Privacy Act, the provisions of this Act prevail. 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 (including adoption 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 information, personal information bank and public body. Child and family services agencies and authorities are listed in regulation as government agencies.

Schedule B in the Freedom of Information and Protection of 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 (MH) 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

The Archives and Recordkeeping Act (ARA) applies to the retention and destruction of a record as defined in section 1 of that Act. 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 Child and Family Services Act and The Adoption Act.

Policy

Terminology
Minimum Requirements
Case Categories
Confidentiality and Access
Record Retention
Printing and Retention of Email

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 (sections 1 of the Adoption Regulation).

Agency Service Record – a service record (see definition below) 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 (see definition above) 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 (see Case Categories).

Case Record – all records and documents relating to a case. This broad definition includes information collected and recorded at intake. In the Child and Family Services Information System (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 (see definition below).

File – has the same meaning as record (see definition below).

Person Record – a CFSIS record containing information about persons involved in a case.

Record – a record as defined in section 1 of The Child and Family Services Act and section 1 of The Adoption Act. Also see service record.

Service Record – a record of services provided to a person or family under The Child and Family Services Act or The Adoption Act. In this section, service record has the same meaning as case record (see definition above).

Minimum Requirements

Agencies are expected to employ service record 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 Child and Family Services 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 with agency record authority schedules (see Record Retention below)

Child and family services agencies must use the provincial automated Intake Module for services to families and child protection interventions under The Child and Family Services Act (see Policy in Section 1.1.1, Intake). This policy is not limited to agencies designated to provide joint intake and emergency services under section 21 of The Child and Family Services Authorities Act.

General Authority agencies are required to use the Child and Family Services Information System (CFSIS) for recording services not included in the Intake Module. All other child and family services agencies are required to use CFSIS for cases that are a provincial financial responsibility and are new or were transferred after November 23, 2003.

The majority of person records are created in the Intake Module. CFSIS is used to add a new family member and when a case is opened for ongoing service. The Intake Module automatically creates a CFSIS case when a decision is made to provide ongoing services and when child abuse is confirmed or the results are inconclusive.

You cannot close the Intake Module record and open the case for ongoing services or transfer it to a receiving agency that has accepted it until you have completed the Authority Determination Protocol (ADP).

Case Categories

Agencies are required to maintain records by case category regarding services they provide to individuals, families and children under The Child and Family Services Act and The Adoption Act. This policy applies to both paper and electronic records.

The case categories listed in this section pertain to services under The Child and Family Services Act and The Adoption Act. For the most part, they are consistent with the categories used in the Child and Family Services Information System (CFSIS).

Adoptive Applicant (AdA) – This category pertains to persons applying to adopt a child under Part 3 of The Adoption Act. It covers agency involvement from the application through to the granting of an order of adoption. It applies to both child and family services agencies and licensed adoption agencies.

Child in Care (CIC) – This category pertains to children in care through voluntary placement (VPA), voluntary surrender of guardianship (VSG), apprehension, or order of guardianship. It does not include children who remain with or are returned to a parent or guardian under an order of supervision.

Child in Care – Supervision (Sup) – This category pertains to children in care (see definition above) whose care and supervision is provided by a supervising agency on behalf of an agency that has legal care of the child through a service agreement or court order. It includes children transferred from an agency outside Manitoba, but not children transferred to an agency outside Manitoba.

Expectant and Single Parents (EPS) – This category pertains to records of services provided to birth parents. In CFSIS, it is a sub-category of a Protection or Voluntary Family Service case. Most agencies use this sub-category for minor parents.

Foster Care Management (FCM) – This category includes the screening, approval and licensing of a foster home under the Foster Homes Licensing Regulation.

Incidental Service Record – This category applies to general enquiries regarding agency services, and requests for services more appropriately provided by another human service organization (see Standard No. 2 and 3 in Section 1.1.1, Intake). Records created under this category typically involve a single contact. For enquiries and requests requiring use of the Intake Module, the worker opens an intake case and records details not covered in the module as an intake note. For foster home and adoption enquiries and referrals using CFSIS, an incidental service record consists of a person record and a pending case record.

Post-Adoption (PA) – This category pertains to post-adoption services provided under Part 4 of The Adoption Act and the Post-Adoption Registry Regulation.

Protection (Prt) – This category applies to child protection investigations and interventions under Part III of The Child and Family Services Act.

Voluntary Family Services (VHS) – This category applies to services provided under Part II of The Child and Family Services Act with the exception of the placement of a homemaker to care for a child in the absence of a parent.

Note: Agencies may use other terminology for case (service) categories for paper filing systems and non-CFSIS computer records. For example, a child and family services agency may open a family file on a voluntary family service or child protection case, a ward file for a child in care or a foster home file on a foster care management case. A licensed adoption agency may open a birth parent file on an expectant and single parent case.

Confidentiality and Access

Agencies are expected to have written policies regarding confidentiality and access provisions in section 76 of The Child and Family Services Act and section 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 – The above statutory provisions require agencies to use discretion regarding disclosure of information from a service record either verbally or through copies or written summaries. For example, an agency may share relevant information regarding a child in care to assist police in a criminal investigation providing it is for the protection of or in the best interests of the child.

Service Record Access Policies – Agency policies must facilitate a person's right to examine or obtain a copy of his or her service record or a summary of the record under section 76 of The Child and Family Services Act.

Service Record Retention

Records generated in the course of providing services under The Child and Family Services 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 record authority schedules, which authorize the retention and disposition of the records and serve as a plan for managing the records through their life cycle. The Child Protection 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 must 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 record authority schedules. Copies of these schedules are available through the following departmental contact:

Records Management Coordinator
Finance and Administrative Services
Family Services and Consumer Affairs
400 –326 Broadway Winnipeg MB R3C 0S5
Phone: (204) 945-4258.
Fax: (204) 945-2760
Email: Bfrey@gov.mb.ca

The records management coordinator is also the first point of contact for transferring records to and retrieving them from the Government Records Centre.

Agencies should also refer to Government Records Procedure GRO 3, Transferring Government Records available on the Government Recordskeeping website. Follow the links under Managing Records in the Manitoba Government to find instructions on how to transfer records to the Government Records Centre and Archives and other information and procedures.

Printing and Retention of Email

General Records Schedule 0001 was created through the Government Records Office and is legally binding on government bodies including child and family service agencies. It states in part that a record of most emails need to be maintained byprinting the email, placing the paper copy on file, and deleting the electronic record. However, the schedule permits the immediate destruction of emails of transitory value such as requests for meetings or messages that a person has called (see Government Record Keeping on the Government Records Office website).
Discretion is required as to when emails are printed to file. The following examples are intended as guidelines in this regard:

• A receptionist sends an email to a worker with a message from a client requesting a home visit be rescheduled. The email contains the name of the client and case number. Unless there is an issue around avoiding contact with the agency or a duty to review a case, the information in this email is of no real value and should not be printed and filed.
• An email may not contain the name or file number of a client, but contains important information related to a meeting with a supervisor or worker regarding the client. This email should be printed and filed.
• A receptionist sends an email that a client called or came to the office. It should not be printed and filed unless the client had a duty to report to the worker. If the message demonstrates the client had at least made an effort to fulfill his or her duty, this information is important to a case and should be printed to file.

Standards

The provincial standards in this section are grouped under the following headings:

Record Management Practices – agency policies and procedures with respect to the management of service records including disclosure of or access to information.

Record Storage and Security – ensuring that service records are stored securely and accessed only by authorized persons.

Record Authority Schedules – complying with government records authority schedules.

Record Management Practices

1. 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
   
   
   
   
2. 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 Information System (CFSIS), the intake worker opens a person record and records the required information as an intake note, but does not open a case record.


3. Case Decisions at Intake – When preliminary information indicates that a referral is appropriate, intake records are opened, transferred or closed under the appropriate case category and the date of the opening, transfer or closure is recorded on file (see Intake Disposition in Section 1.1.1)..


4. Content of Intake Records – At minimum, agency intake records contain the following information:
   
   
   • for a child and family services agency, personal and case information gathered through the use of the Intake Module (see Section 1.1.1)
   
   
   • 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
   
   
   • when applicable, information on the level of risk to a child and the recommended priority to be given a case (see Level of Risk in Section 1.1.1)
   
   
   • names of the intake worker(s) and supervisor(s) involved in the case
   
   
5. Content of Records Opened for Ongoing Service – At minimum, records of cases opened for ongoing service contain the following information:
   
   
   • personal and case information recorded at intake (see Standard 3 above)
   
   
   • applicable initial and updated agency assessments and reports such as family assessments, child assessments, court reports and homestudies
   
   
   • 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 electronically stored information (see Standard 6 below)
   
   
   • case notes by date recorded relating to further information obtained or received, client and collateral contacts, services provided and case decisions
   
   
   • names of the case manager and supervisor and of service providers involved in the case
   
   
6. Current Photographs of All Child in Care – An agency ensures that current photographs of all children in care are available on file and with caregivers. This requirement is particularly important in the event a child is reported missing and it will greatly assist the police.


7. 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 Child and Family Services 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.


8. 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
   
   

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.

9. Child Protection and Voluntary Family Services Cases – A record is opened as or changed to 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. When a voluntary family services (VHS) case is changed to a protection (Prt) case, the agency informs the person or family pursuant to subsection 76(13) of the Act. The case category is changed to VHS when there are no longer child protection concerns and the person or family has requested ongoing services. The reasons for and dates of case category changes are recorded.


10. Transfer and Closing Summaries – When recommending that a service record be transferred or closed (see Section 1.1.6), an intake worker or case manager, as the case may be, 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
    
    
    • date record closed
    
    
11. 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. For example, case notes stored in a paper file should indicate by date of recording if they pertain to a child protection or voluntary family service case. Voluntary placement agreements, voluntary surrender of guardianship and orders of guardianship should be stored on child-in-care files.


12. 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 Child and Family Services Act and section 104 of The Adoption Act
    
    
    • to offices that have statutory authority to access or obtain copies of records including the Ombudsman, Chief Medical Officer, Children's Advocate, the Director of Child and Family Services and an agency's mandating authority
    
    
    • in accordance with confidentiality and access policy in this section
    
    
13. 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, by a parent or guardian, records the nature and date of the request and what action was taken in response to the request.


14. 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.

Record Storage and Security

15. 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.


16. 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.


17. 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 Child and Family Services Act and subsection 9(2) of the Child and Family Services Regulation.


18. 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.

Record Authority Schedules

19. Designated Persons to Administer Schedules – An agency ensures that appropriate staff are assigned responsibility for administering provincial record authority schedules in each office of the agency and to coordinate transferring records to or retrieving them from the Government Records Centre.


20. Regular Scheduling of Records – The designated persons in Standard 15 above schedule reviews of all its service records at least once a year to determine which records should be sent 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 unless the record must be sent to the centre according to the schedule.