Guidelines for effective case recording
We have seen in the foregoing discussion that social case records are an essential component of social case work practice. Case recording is not only an important practice tool and skill; it reflects the very effectiveness or lack of effectiveness of case work practice. Good records are the primary proof of quality of care; they are rather part of standards of care of and service to the clients.
It is important to follow certain guidelines so that recording remains within code of professional ethics. Guidelines are also relevant because the characters in case records do not speak for themselves. They obtain a hearing only in the translation provided by the language of the social worker. It will be worthwhile that students make note of the guidelines given below
Stick with the facts. Recorded information should be factual, accurate, objective and necessary.
i) Factual – Describe objectively what you see, hear, smell, physical and behavioural changes.
ii) Facts and your opinions or inferences should be mentioned separately. Your hunches or opinions should not be used as facts which provide rationale for your decisions.
iii) Accurate – Document sequence of all events as they occurred. Be sure to include the who, what, where, when, the time, place, and persons involved.
iv) Complete: If you didn’t document it, it didn’t happen. Document all contacts, telephone calls, patient/family contacts and consultation with other professionals, and collaborations with other care agencies.
v) However, process of selection is important in documenting case work records. Even in process recording, principle of selection is applicable.
Experience and training goes a long way to acquiring ability to select significant information from a mass of data collected.
Recorded information should be clear, concise, and specific.
Clarity of language: Practitioners should use clear, specific, unambiguous, and precise wording.
Services provided should be clearly identified.
Assessment of the client-situation-problem/concern should be necessary component of case records. Mention treatment/problem-solving interventions provided – based on professional assessment that can be supported with evidence.
It is very risky to document conclusions with terms or phrases such as “the client was confused” or “the social worker behaved aggressively toward the client” without including supporting details. You, therefore, need to always include explanatory details that support a conclusion or assertion.
Timely : Records should be written down when the worker’s memory is clear of the events. Few social workers relish the task of documentation, whether for clinical, supervisory, management, or administrative purposes. Documentation takes time and often looms as an onerous task—a necessary evil associated with professional life. As a result, social workers sometimes put off documenting their observations, decisions and actions. Delayed documentation can compromise the credibility of social workers’ claims about what is reflected in the notes.
Avoiding advance Documentation. In an effort to save time and expedite documentation, social workers occasionally record notes in advance of an intervention or event. Sometimes, however, the planned interventions or events do not occur or unfold differently than expected. The prematurely recorded notes would therefore be not accurately reflect what happened and thus would undermine the social worker’s credibility.
Do not air agency’s dirty laundry. Details concerning understaffed programs or personal opinions about the competence of a colleague do not belong in a client’s record.
Ensure confidentiality of records, whether stored as paper files or as electronic data. Some social workers maintain separate records for sensitive information that must be protected and joint files for more routine assessments and summaries of services provided. For example, a social worker who provides an individual counselling session to one member of a couple, as a supplement to counselling the couple, can create a separate file for that client in which private issues, such as a report of struggles with sexual orientation, family violence, or substance abuse, are recorded. In the couple’s joint file, the social worker would record the fact that they sought marital counselling to address “relationship issues.” Maintaining separate records in these circumstances may help the social worker protect each individual client in the event that a dispute arises, for example, a child custody dispute or divorce.
Records should reflect the worker’s competence, thoughtfulness, decision-making ability, and capacity to weigh available options, rationale for treatment selection and knowledge of clinically, ethically and legally relevant matters. These should also help in identifying the worker’s errors so that the same may be rectified.
Do not alter records if hindsight brings up some gaps or errors in practice.