Chapter 16: Recording in Generalist Social Work Practice
Identifying the Client and the Need
You identify who your clients are and specifically the problems they bring to you. Recording their existence and situations make them part of your case load. Caseload is the total number of clients a social worker is accountable for.
Recording information helps you explore the nature of your clients strengths, needs, and problems and also helps you plan/structure how you will proceed with intervention. This is also helpful for monitoring clients progress
Documenting Services
When a colleague or supervisor ask what you do, you can refer to your documentation to describe your assessments, plans, interventions, evaluations, terminations and follow-ups. Documentation proves you have accomplished what you say you have accomplished
Maintaining Case Continuity
Having access to what has been done in the past is much more efficient than starting from scratch. Since workers come and go, accurate recording allows clients to be transferred with minimal interruptions in their services. Having documented who the client is and what has been done allows for new workers and other professionals to begin where the last intervention left off.
Assisting in Interprofessional Communication
Recording information and sharing it in writing provides efficient and effective means of communicating with others involved with the client.
Sharing Information with the Client
Sharing information with the client can be helpful. It can clarify their strengths, problems, plans or achievements. You should also be sensitive to how your client might react to the written record.
Facilitating Supervision, Consultation, and Peer Review
Recording your perceptions and progress will provide a means for you to get direction, feedback and help from other professionals.
Monitoring the Process and Impact of Service
Interventions and plans help organize your thinking about how to proceed with clients. Recording information about clients progress or lack thereof provides you with clear-cut descriptions of your clients situations at any particular point in time.
Educating Students and Other Professionals
Social work records can provide excellent means for educating both students and practitioners already in the field about effective interventions.
Supplying Information for Administrative Task
Large and small social service agencies must keep track of the services they provide and how effective these services are. They are accountable for their work just like individuals. Administrative personnel must attend to issues in service delivery like service patterns, workload management, personnel performance and allocation of resources.
Providing Data for Research-Informed Practice
Recording information about large numbers of clients can contribute to a database that is very useful for research. This helps improve effectiveness of agencies and organizations.
Identify Content Contained in Records
Date of Interaction with Client
Basic Information about Client
Commonly called “face sheet”, which is a page of information at the beginning of a client file/record. Includes basic identifying information like name, address, phone number, income, family member names, and reasons for referral.
Reason for Client Contact
What is the clients problem/situation?
Usually a brief amount of the primary problems described
More Detailed Information about Clients Problem/Situation
Put the most relevant information to the clients problem like their strengths
Could be very brief or relatively detailed
More information usually gathered in a “social assessment report”
This is a comprehensive portrayal of a clients current situation and past developed by gathering information about the clients development, family, interpersonal relationships, education and socioeconomic status
Aspects of the Implementation Process
This information includes your impressions concerning assessment of client-in-situation, plans for intervention, contacts you have had with clients and others involved in case, progress made and information about how the case was terminated
This section usually has brief entries for contact and calls during case
Follow-Up Information
Is there a plan for follow up? Usually if so it will be recorded
Comments/Questions to Discuss with a Supervisor or Another Worker
You can add questions or comments you might have to the case
Employ a Range for Recording Formats
Social workers use a wide range of recording formats for many purposes. These formats include process recording, digital recording, progress notes, narrative recording, summaries of treatment conferences, problem-orientated recording, recording progress in groups, letters, e-mails, memos, and meeting agendas and minutes
Progress Recording requires that the recorder must:
Reconstruct the interview
Describe the words they spoke and actions they took
Reflect on the way in which they used themselves in the interview
Assess their practice
Name the specific skill they were using at the time
Attend to Technological Advances in Record Keeping
Technology will continue advancing. It is important for social workers to continuously keep abreast new approaches and methodology.
Employ Good Writing Skills in Recording
Writing skills usually improve with practice, you tend to become more accustomed to writing memos and selecting certain types of words to use. Colleagues and supervisors can be helpful
Examine Privacy Principles with Respect to Recording
There are 5 privacy principles to the social work practice.
Confidentiality - ethical practice that workers shout not share information provided by client or about client unless give explicit permission to do so
Access - refers to the clients right to see what or how information is being recorded
Anonymity - refers to using recorded information about clients but omitting identifying data.
Security - protects privacy through a system of administrative policies and procedures
Abridgment - refers to restricting type of information that is put into the record and period of time over which the record can be retained