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Office of the Director of Social Welfare

Documentation
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ETHICS

Documentation

What happens when one does not document decisions?

Brief Case

 

“I have been in practice for 28 years and I’ve never kept detailed notes. I just wasn’t trained that way. Are you saying my word about what happened isn’t good enough?”

Brenda replied tersely to the panel in a formal ethics hearing when requested to produce copies of her clinical notes by the chair of the committee.

Brenda is a clinical social worker specialized in the treatment of depression, anxiety, interpersonal conflict, and other mental health issues. One of Brenda’s clients had filed a formal ethics complaint against Brenda with the state board. The client alleged in her complaint that Brenda was unethical in the way she abruptly terminated services and Brenda’s “abandonment” directly caused her despair and subsequent suicide attempt. Brenda testified before the panel how the challenging clinical situation was handled professionally and ethically. Brenda shared in the hearing how she discussed issues with colleagues in her peer consultation group, telephoned a psychiatrist who specializes in the treatment of individuals who have been diagnosed with borderline personality disorder, and carefully planned for the termination of services.

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Responses by social workers:

Documentation in social work practice is something that cannot be avoided by professionals in our field. While laborious to maintain, well-kept documentation can protect workers from liabilities in the event of malpractice suits.

Aside from the purpose of protecting workers from civil liabilities, it is also important to understand how clear documentation of our work can also serve as a means to improve the standards of clinical services that are rendered toward our clients. For instance, clear and timely documentation of the treatment interventions that has been provided to our clients can better inform the assessment of workers who may have to take over the particular care of a client after his current worker leaves his current position. While, description of daily behavioural observations or critical incidents of our clients allows other workers to have a more balanced view of how the functioning of our clients came to be.

Therefore, it is important to recognise that while one purpose of well-kept documentation lays in its purpose to safeguard the worker against legal liabilities, the practice of documentation can also be meaningful to practitioners as it can serve as a means of ensuring that clinical services and standards to our clients are not comprised when their workers leave the organization.

​Eric Goh

Correctional Rehabilitation Specialist
Singapore Prison Service

Commentary

Reprinted and Adapted with the permission of Social Work Today ©. Great Valley Publishing, Co.
“Never Underestimate the Power of Documentation” by Dr Frederic G. Reamer, Social Work Today, Published on 29 October 2001

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

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