Type of Case Recording

For the purpose of recording the above-mentioned areas of information, different forms of case records are employed by the practitioners. Some are used more frequently than others. Different types of records are used jointly or simultaneously because they complement each other.  Here are some of the different type of case recording 

1- Process records:

They provide moment-by-moment narrative of clients’ behaviour and interactions, between practitioners and clients. Process records give almost verbatim account of each session or encounter the worker with the client and/or others, and of home visits. Process records also include the worker’s thoughts, opinions and feelings, although they have to be specified as such and not as facts. This type of record is frequently used in educational and supervisory processes and forms the basis of students’ experiential learning

2- Summary records:

These records are very important in situation in which long-term, ongoing contact with a client, and a series of workers may be involved. Summary records primarily include entry data, sometimes social history, a plan of action and periodic summaries of significant information and action taken by the worker, and a statement of what was accomplished as the case was closed (closing summary). Periodic summaries may be made at specified periods of time like every two months or after every 5 sessions or they may be made when it is necessary to document some fact or action. It is focused more on what happens with the client rather than on the worker’s inputs. Summaries may need to be updated from time to time.

3- Problem-oriented record:

 These are particularly useful for social workers employed in interdisciplinary settings like health care agencies. These records contain four parts. First is the data base that contains information pertinent to the client and work with the client. Second is a problem list that includes a statement of initial complaints and assessment of the concerned staff. Third are the plans and goals related to each identified problem. Fourth are follow - up notes about what was done and the outcome of that activity. Problem-oriented records usually consist of two forms: checklists; and a narrative based on SOAP format, that is, subjective – patient’s report, objective – facts as determined by clinical activity, assessment – a statement about the nature of problem, and plan – for dealing with the problem.

4- Standardized forms:

 These summarize client information using short answers or checklists. These forms are developed by many agencies serving a specific client group like the mentally challenged or ill or the abused and battered, to get uniform set of relevant information. In recent years, more structured and systematized forms of recording are being used for ordering information, checking its validity, and drawing up and testing hypotheses.

5- Case Notes:

These are the records of worker’s intuitive observations, reflections on treatment or interventions provided, and mentions of critical or significant incidents. Reading through last week’s notes may make the worker have certain expectations of ‘this week’s’ session. Keeping notes helps him to remember particular details, and to plot the progress of the client.  Out-of-office experiences, such as home visits, attending weddings or funerals, going on hikes or for tea in a restaurant, taking a client to a medical or a specialist’s appointment, and clinically meaningful incidental/chance encounters are also included in case notes.

6- Log or Journal Entries:

Logs or journals can be very useful in some fields of work. Someone who meets with a lot of different people in his or her work might keep a log or journal as a personal record of meetings and what was discussed. Note taking means jotting down details of meaningful contacts, including important phone calls and important or clinically significant collateral contacts, at the first opportunity. These notes act as aids to memory or recall at the time of actual documentation.

Card Files: In some agencies, like schools, data about the case work with a client are maintained on cards, which can be easily retrieved and give thumbnail picture of the entire case work done till then. Brief entries are made after each encounter and progress reviewed.

These are some of the forms in which social workers may document case records. More than one form may simultaneously be used for one client.

Reference-

• Reamer, Frederic G., Documentation in Social Work: Evolving Ethical and Risk-Management  Standards, Social Work, 2005 Oct, vol. 50 no. 4: pp 325-34. Kagle, Jill  Doner, Social Work Records, Dorsey Press, Homewood, Illinois, 1984.
•  Ames, Natalie, Social Work Recording: A New Look at an Old Issue, Journal of Social Work Education, 1999 Vol. 35. 
• Foster, Michele; Harris, Jennifer; Jackson, Karen; and Glendinning, Caroline, Practitioners’ Documentation of Assessment and Care Planning in Social Care: The Opportunities for Organizational Learning, British Journal of Social Work, 2008  38(3):546-560. Huuskonen, S., Documentation and Use of Client Information System by Social Workers in Child Protection Services, Information Research, 2008 13(4). Wilson, Suanna, Recording: Guidelines for Social Workers, Free Press, New York, 1980. 
• Young, Pauline V., Recording of the Interview, Appendix B in Interviewing In Social Work:  A Sociological Analysis, Mcgraw-Hill Book Company, Inc., New York, 1935. 
• Sheafor, Bradford W., Horejsi, Charles R., Techniques and Guidelines for Social Work Practice, Pearson Education, Inc., Boston, Seventh Edition, 2006.