Commentary

As in this case example, social workers sometimes find themselves in situations where they must be able to provide evidence of their conduct and actions during some time in the past—whether the immediate or distant past. This may occur in the context of litigation (for example, when a former client files a malpractice claim alleging some kind of professional negligence) or adjudication of an ethics complaint filed with a state licensing board or the National Association of Social Workers. Although most social workers understand the importance of careful and thoughtful documentation, some do not.

The bottom line is that careful and diligent documentation enhances the quality of services provided to clients and, ultimately, can protect practitioners. As the NASW Code of Ethics states, “(a) Social workers should take reasonable steps to ensure that documentation in records is accurate and reflects the services provided. (b) Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future” (standard 3.04). Comprehensive records are necessary to assess clients’ circumstances, plan and deliver services, facilitate supervision, provide proper accountability (to clients, other service providers, funding agencies, insurers, utilization review staff, and the courts), evaluate services provided and ensure continuity in the delivery of future services. Skilled documentation also helps to ensure quality care if a client’s primary social worker becomes unavailable because of illness, disability, vacation, or employment termination. Also, thorough documentation can help protect social workers who are named in lawsuits or ethics complaints.

In typical clinical settings, documentation should ordinarily include (Reamer, 2001)

• a complete social history, assessment, and treatment plan that states the client’s problems, reason(s) for requesting services, objectives and relevant timetable, intervention strategy, planned number and duration of contacts, methods for assessment and evaluation of progress, termination plan, and reasons for termination;
• informed consent procedures and signed consent forms for release of information and treatment;
• notes on all contacts made with third parties (such as family members, acquaintances, and other professionals), whether in person or by telephone, including a brief description of the contacts and any important events surrounding them;
• notes on any consultation with other professionals, including the date the client was referred to another professional for service;
• a brief description of the social worker’s reasoning for all decisions made and interventions provided during the course of services;
• information summarizing any critical incidents (for example, suicide attempts, threats made by the client toward third parties, child abuse, family crises) and the social worker’s response;
• any instructions, recommendations, and advice provided to the client, including referral to and suggestions to seek consultation from specialists (including physicians);
• a description of all contacts with clients, including the type of contact (for example, in person or via telephone or in individual, family, couples, or group counseling), and dates and times of the contacts;
• notation of failed or canceled appointments;
• summaries of previous or current psychological, psychiatric, or medical evaluations relevant to the social worker’s intervention;
• information about fees, charges, and payment;
• reasons for termination and final assessment; and
• copies of all relevant documents, such as signed consent forms, correspondence, fee agreements, and court documents.

Understandably, few social workers relish the task of careful documentation. The time and effort required can be daunting and consuming. Yet—as many social workers have learned by default in the face of a disgruntled party’s allegations—a carefully documented record can turn out to be your best friend.

— Frederic G. Reamer, PhD, is a professor in the graduate program of the School of Social Work, Rhode Island College. He is the author of many books and articles, and his research has addressed mental health, healthcare, criminal justice, and professional ethics.
Reference
Reamer, FG. (2001). The social work ethics audit: a risk management tool. Washington, DC: NASW Press