Today s Presentation 07/11/2014. New and Improved? Making the Shift to Electronic Records

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1 New and Improved? Making the Shift to Electronic Records OASW Conference November 15, 2014 Lise Betteridge, M.S.W., RSW Deputy Registrar Today s Presentation The College and its Mandate The Standards of Practice and Documentation Electronic vs. Paper Commonalities and Challenges Questions? 1

2 Regulation Professionals: To protect the public interest from unqualified, incompetent or unfit practitioners Self-Regulation: Government delegates to a profession the power to regulate its peers Profession has special knowledge to set standards and judge conduct through peer review Regulatory Context Social Work and Social Service Work Act, 1998 Ontario College of Social Workers and Social Service Workers (OCSWSSW) Fully proclaimed on August 15, 2000 The OCSWSSW Confers and protects the title for those with specialized academic qualifications who meet rigorous standards Supports lifelong learning: continuing competence & professional development Code of Ethics and Standards of Practice Provides oversight and discipline 2

3 Code of Ethics and Standards of Practice The Code of Ethics and Standards of Practice Handbook, 2 nd Edition: 8 Principles to guide conduct To set out minimum standards of professional practice and conduct To prescribe basis on which professional practice is conducted in a sound and ethical manner To guide and assess professional behaviour and practice Other College Resources Practice Guidelines Practice Notes Perspective Newsletter AMED and Regional Forums Practice Consultations Professional Practice Department Paper or Electronic? Change is already here in most settings Standards of Practice apply to both The principles are generalizable 3

4 Why Document? To ensure there is an official record of events, assessment, interventions, decisions and plan To fulfill legal requirements and meet professional standards To communicate To ensure accountability To promote quality assurance To provide useful information for research and education For Whom? College Public Protection Minimum Standards Principles to Guide vs. Prescribe Professional Judgment SW/SSW Risk Management Best Practices Client Care Accountability Communication Adapted from Shastri-Estrada, Serena, COTO, Presentation at Grandview Children's Centre, January 23, 2013 Principle IV: The SW and SSW Record The purpose of the social work and social service work record is to document services in a recognizable form in order to ensure the continuity and quality of service, to establish accountability for and evidence of the services rendered, to enable the evaluation of service quality, and to provide information to be used for research and education. 4

5 Principle IV: The SW and SSW Record College members ensure that records are current, accurate, contain relevant information about clients and are managed in a manner that protects client privacy and in accordance with any applicable privacy and other legislation. Principle IV: The SW and SSW Record, cont d Recorded information conforms with accepted service or intervention standards and protocols within the profession of social work and social service work College members do not make a statement in the record, or in reports based on the record that the member knows or ought reasonably to know is false, misleading, inaccurate or otherwise improper. Principle IV: The SW and SSW Record, cont d College members inform clients early in their relationship of any limits of client confidentiality including with respect to the client record. 5

6 Principle V: Confidentiality 5.1 College members comply with any applicable privacy and other legislation. 5.4 College members inform clients early in their relationship of the limits of confidentiality of information. Principle IV, Footnote 2 An accurate record will: (a) document the client's situation/problem exactly and contain only information that is appropriate and useful to the understanding of the situation and the management of the case; (b) report impartially and objectively the factors relevant to the client's situation Principle IV, Footnote 3 Information in the social work and social service includes f) Particulars of the social work or social service work process, as applicable: i) the history obtained by the member; ii) assessment, diagnosis, formulation and plan; iii) treatment and other interventions 6

7 The Electronic Record Unique Issues Record format Recording sensitive information Access to the electronic system Increased use of templates Record Format According to the minimum requirements set out in Principle IV: The SW and SSW Record, Footnote 7, an electronic record must: Limit access - private access code or password Maintain an audit trail date and time of each entry Indicate changes Preserve original content Recording Sensitive Information Increased access by other staff Centralized record PHIPA and the lock box Personal or parallel files 7

8 Parallel or Personal Files May have been common practice What is the impact of limiting access by others involved in the client s care? Consider the client s best interests What is the rationale? Parallel or Personal Files, cont d. Employer Policy Storing supplemental tools Legal issues Storage of the paper or parallel file The Electronic Record Access to the System Standards require members to document their own actions Record must reflect the identity of the service provider System must be protected from unauthorized access, Principle IV: The SW and SSW Record, Footnote 7 Private password or access code required Use of electronic signatures 8

9 The Electronic Record Use of Standardized Templates May increase uniformity, clarity and efficiency Must meet minimum requirements in terms of content Avoid communicating a diagnosis Resources Practice Notes on Record-keeping: The Broken Record Practice Notes on the Electronic Record: New and Improved? Making the Shift to Electronic Records Visit the Resource Room/College Publications on the College website at To Conclude Change is here Standards of Practice are relevant, applicable and generalizable Some specific standards and unique issues to consider 9

10 Questions? More Questions? Lise Betteridge, M.S.W., RSW Deputy Registrar ext