RECORDING AND DOCUMENTATION IN SOCIAL CASEWORK

Social caseworkers keep records to document and retain information about their clients and the process and progress of their services. Individual case records are used in planning, implementing, and evaluating services to each client.  Aggregated records are used in planning, monitoring, and evaluating services to a group of clients. …The case record is a focal point for accountability to the client, to the organization, and to the profession. (Kagle, p.1). Among Standards for Clinical Social Work in Social Work Practice established by the National Association of Social Workers, documentation is mentioned as a required responsibility of social workers, “Documentation of services provided to or on behalf of the client shall be recorded in the client’s file or record of services”. (Standard 8, 2005)

Purpose and functions of case recording and documentation

The field primarily looks at documentation’s function as a diagnostic, assessment, planning, and intervention instrument although in recent times, records perform several other functions as well. Kagle (1984) has defined social work records in terms of their focus, scope, purpose, and functions.

• The focus of records is to individualize and typify the client, the need, the situation, and the service transaction;
• Scope includes linking goals, plans, and activities to the assessment of the client-need-situation and to the resources available; and
• Purpose is to facilitate the delivery of services to or on behalf of the client; and
• The record Functions as an important resource in communication about the case, while the process of recording involves reviewing, selecting, analyzing, and organizing information about it.

Uses and Functions of Social Case Records:

1. Identifying client and client’s need – The social case record describes the client, his characteristics, needs, concerns or problems, situation, and his social environment. These particulars assist the worker in planning client care and services that are necessary.
2. Provide a basis for deciding the client’s eligibility for receiving service from the particular agency.
3. Documenting the activities undertaken and services rendered to the client or on his behalf. This documentation helps in client’s securing reimbursements (if applicable), in demonstrating adherence to procedural guidelines provided by organizations or funding agencies. Records, if maintained regularly, demonstrate activity and movement in the helping process and facilitate decision-making by the social case worker.
4. Assessment and Planning: Clear and comprehensive documentation of all case-related facts and circumstances is essential for assessment and service planning related decisions. Recording information is seen as one of the essential skills of the assessment process. Careful and thoughtful information collection ensures that social workers have an adequate foundation for their reasoning and intervention plans.
5. Evaluating the client’s condition and ongoing treatment. Records document the course of the client’s evaluation, treatment, and change in condition including the impact of services on the client. Measured outcomes and service effectiveness are central to social casework. At their core lie data and information recorded throughout the helping process.
6. Documenting communication between the worker and other professionals contributing to the client’s care. In interdisciplinary settings like health care and mental health agencies, rehabilitation services, child care agencies, schools, and correctional settings, social case records serve as a vehicle for interprofessional and interagency coordination and collaboration.
7. Records serve as bases for the peer review system. Peer review of social casework documentation helps promote the uniformity and consistency with which services are delivered, and workers are exposed to the professional practice of their colleagues. In health care settings, especially, records have the potential to help identify patient problems that need not be met by the existing system of health care delivery; such gaps in service can then be brought to the attention of the management of the medical care center for consideration and possible resolution. Peer review of records also helps enhance social worker performance and service delivery.
8. Maintaining continuity and co-ordination: Good documentation plays an important role in passing information between social workers especially
9. In situations where the workforce is changing like when the client is transferred to another social worker, either due to a change of assignment, leaving job, or end of field placement term (in case of social work trainees).
10. For service planning – e.g. the documentation can produce information about children’s passage through the services (from children’s homes to foster care or aftercare) and the number of children using these services.

• In case of gaps in contact with the client, either due to the client’s or worker’s absence for a protracted period; or

1. The client’s situation and problems are complicated, requiring multiple and extensive interventions. Records help in maintaining thematic continuity to get a comprehensive overview of the case and services rendered.
2. Sharing information with the client: In contemporary social work practice, clients can access information contained in their case records. While it puts pressure on the worker and his relationship with the client, it can be seen as facilitating the client’s review of the information shared with the worker, and the client’s participation in the helping process. Various methods may be used to involve clients in recording and evaluating all that is being done with the client or on his behalf.
3. Demonstrating and measuring worker accountability: Records thus serve as instruments of evaluating professional practice; to sensitize workers to practice within parameters of professional ethics and values; and legal safeguards.
4. Administrative tasks, like decisions about client needs and services to be offered, and budgeting are done by using social case records.
5. Social work education and field instruction: Social casework records have traditionally served as a tool for educating future social work professionals both in the classroom and on the field. Case records, if used appropriately, prove excellent classroom teaching aids. For experiential learning, they are necessary accompaniments to field instruction. Process records submitted by students form the basis for the supervisory process, which is an integral part of social work education.
6. Research for practice improvement and theory building: Aggregated records or case records taken singly provide important qualitative data for summative (for example, arriving at a collective description of client attributes, problems, or services required by the clients) and formative (for evaluating practice effectiveness and areas for improvement, undertaking qualitative analysis of the interviews, observations, and interventions) research. Records provide essential data for broader service program evaluations. In the early years of professional development, data from case records were used for building social work theories.
7. Protecting practitioners- Social workers, in many countries, have begun to recognize the significance of documentation as a liability shield and risk management tool. Records provide evidence in case they have to defend themselves against ethics and complaints. Without thorough documentation, social workers may have difficulty defending their actions.
8. Organizing thoughts and information and facilitating recall: The process of recording helps the practitioner to organize and crystallize his thoughts about the client’s situation, hunches about what needs to be done, and likely plans of action. The worker collects a vast amount of information about the client’s situation/problem environment. To offer professional intervention, this information has to be organized and analyzed. Very often, despite there being a lot of information, some vital pieces of information may be missing. The process of recording helps locate such gaps and encourages further exploration. Also, the process of documenting the worker’s activities and client responses acts as an aid to the worker’s memory of all that occurred in the client-worker encounter or at different phases of the helping process.

Content of Records

What goes into a social casework record depends on who it is for. There are a number of persons who access or use it: the practitioner, the agency or college supervisor, the funding agency, the collaborating agency, or the legal system. Too much content, too little content, or the wrong content can harm clients and expose practitioners to considerable risk of liability. How comprehensive or selective should be the information that forms the content of the case record?

In the current scene of social work practice, “Practitioners’ first rule of thumb when documenting cases should be to include sufficient details to facilitate the delivery of services and protect themselves in the event of an ethical complaint or lawsuit”. (Reamer, 2005) Considering that records are expected to reflect the unique nature of client-problem/concern-situation complex placed in the agency context, the content of each record will understandably vary. Different approaches to practice, different service delivery patterns, and different procedural requirements in different service environments lead to differential recording. (Kagle, 1984) However, there are some common areas of information that every case record needs to include. That information is relevant for a case record that shows how ‘client-situation-problem’ and available resources form the basis for service decisions and actions. Some of the areas considered essential in case records are given below:

A.      Identifying and demographic details

• An identifying mark like a number or symbol assigned to each case handled by the worker/agency.
• Identifying data about the client – full name, age, sex, religion/caste (if relevant or required), address, contact number, educational and occupational status, income (if relevant as it is a sensitive area for most persons), marital status.
• Social history (demographic particulars to establish client’s social environment) – family composition, educational and occupational status.

B.      Referral

• Source of referral – who has brought the problem or concern to the notice of the worker; the client himself, some family member, agency staff member, from the worker’s own observation, or referred by some authority like court, school authorities, etc.
• Reported reason for seeking help – the immediate reason for approaching the agency – with the date and time of referral, and the date and time of first encounter/action taken by the worker or someone else.

C.      History of the reported problem /concern:

In cases of chronic or mental illnesses; handicaps – mental or physical; marital discord or domestic violence antecedents along with their impact on the client and significant others need to be mentioned. Whether this history covers incidents only of the recent past, from the onset of the problem, or starting from the very childhood will depend largely on the nature of the problem and the procedural requirements of the services to be rendered. For example, for a child reported to be mentally challenged, milestones achieved right from early childhood may be important while information about the precipitating factors leading to the onset of mental illness may be enough in the case of mentally ill persons. In the case of adoptive parents, certain medical tests and facets of family history, not only of the adoptive parents but their respective families as well become necessary.

D.     Reports of any tests made:

by the worker, health/medical/rehabilitation professionals (including mental health workers). For example, the results of previous or current psychological, psychiatric, and medical evaluations, and objective information are based on other independent sources and noted. Data derived from or interpretations of ecomaps, genograms, etc. need also to be included in the case record.

E.      Assessments made:

About the level of the client’s motivation to share responsibility for the helping process, description of problem areas identified by the social case worker; identification of key persons in the problem-solving process; hypothetical statements of their causes and impact; statement of alternate plans of action and grounds for deciding on a particular line of action; measurable goals – immediate, or long term – to be stated

F.       Decisions made and services provided:

actual interventions or tasks performed by the worker, client, or others as part of the service/treatment plan decided upon as a result of the assessment; notes on the progress of the action plan execution

G.     Contacts made with other professionals for consultation or collaborative actions:

Contacts with others – collateral sources of information or for participating in the execution of service/treatment plan.

H.     Final assessment and evaluation of the service rendered.

I.        Information about transfer, termination, or referral.

J.        Closing summary of the entire helping process, period of the helping process, number of sessions with the client, and any critical incidents.

As mentioned earlier, the final content will depend on several factors but the information selected to be contained in the case record has to be balanced and relevant to the particular client and his needs. Essentially, it should provide a comprehensive picture of the nature of the social case worker’s involvement with a particular client, progress in achieving professional goals, and the eventual outcome of the interaction between the worker and the client or agency.

Forms of Case Records

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 usually employed forms of records:

1.      Process records:

They provide a moment-by-moment narrative of clients’ behavior and interactions between practitioners and clients. Process records give almost verbatim accounts 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 situations 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 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 input. 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 database that contains information pertinent to the client and works 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. (Johnson, pp.393)

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 a uniform set of relevant information. In recent years, more structured and systematized forms of recording have been used for ordering information, checking its validity, and drawing up and testing hypotheses.

5.      Case Notes:

These are the records of workers’ 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.

7.      Card Files:

In some agencies, like schools, data about the casework with a client are maintained on cards, which can be easily retrieved and give a thumbnail picture of the entire casework done till then. Some illustrative entries in the card file are as follows:

1)Name ————— 2)Referred on ——— 3)Referral From ——— 4)Initial Assessment —— 5)Meeting 1 ——— 6)Meeting 2 ————— 7)Meeting 3 ————— 8)Review Notes 9)Meeting 4 ———so on —— 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.

Source: Manju Kumar, Recording and Documentation in Social Case Work, Interviewing and Recording,

Egyankosh