How to record a case work ?
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.
Recording and Documentation in Social Case Work
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.
·
Factual
- Describe objectively what you see, hear, smell, physical and behavioural
changes.
·
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.
·
Accurate
- Document sequence of all events as they occurred. Be sure to include the who,
what, where, when, the time, place, and persons involved.
·
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.
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.
1.
Recorded
information should be clear, concise, and specific.
2.
Clarity
of language: Practitioners should use clear, specific, unambiguous, and precise
wording.
3.
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 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, the 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.
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