STANDARDS FOR SOCIAL WORK RECORDING Adopted September 12, 2005
INTRODUCTION Social work recording is grounded in the values, ethics and philosophy of the social work profession and reflects adherence to the Canadian Association of Social Workers (CASW) Code of Ethics and the Canadian Association of Social Workers (CASW) Standards of Practice. Social work recording has long been recognized as a vital component of professional and competent practice in agency, private, and community settings. STANDARDS FOR SOCIAL WORK RECORDING Standard 1 Documentation of social work interventions with clients are contained in one written record (or master file) as per the Canadian Association of Social Workers Code of Ethics. Social workers are required to maintain records on all clients or client systems within that one written record. Standard 2 Confidentiality is an important element in social work recording. Clients, families, groups and communities are made aware of the limits to confidentiality before initiating the social work relationship and throughout the relationship as needed. Standard 3 Assessment is the foundation of social work documentation. Assessments are based upon facts that should be clearly documented. Only facts that are clearly relevant to the assessment and planned intervention should be recorded. Standard 4 Social work documentation must be in a format that facilitates monitoring and evaluation of the social work intervention. Standard 5 Outcomes are important. Documentation must include a plan and the termination of the social work intervention should be clearly documented. Standard 6 Policies should be developed to ensure timely recording and auditing of social work documentation that is consistent with agency standards. Standard 7 Documentation of community development processes, project planning, policy development, and research is grounded in the values, ethics, and philosophy of the profession and reflects adherence to the Canadian Association of Social Workers (CASW) STANDARDS FOR SOCIAL WORK RECORDING 1
Code of Ethics and the Canadian Association of Social Workers (CASW) Standards of Practice. RATIONALE: THE PURPOSE OF THESE STANDARDS Social workers are looking to regulatory bodies and professional associations to provide clear standards to assist with the recording of professional information that follows existing legislation, the Code of Ethics, and social work standards of practice. This document is in response to this need. These standards are not based upon a specific theoretical approach and are intended to be applied across all fields of social work practice. Social work is a regulated profession with a high degree of legal and ethical accountability. Social workers are required to adhere to a Code of Ethics, Standards of Practice, federal and provincial legislation and agency policies. Federal and provincial legislation has been created and amended to address issues of privacy and access to personal information by government institutions, the private sector and public bodies (please see Appendix A for a summary of these Acts). Because social workers are employed in diverse fields of practice, it is important that social workers are aware of these legislative and agency requirements. The law protects some relationships (husband-wife, lawyer-client) against disclosure. However, the social worker-client relationship does not have this legal status. Therefore, having to disclose information, particularly in a court of law is always a possibility. Other circumstances that dictate disclosure are outlined in the CASW Code of Ethics (2005) and include threat of harm to self or others, child abuse, and when it is authorized by the client. It is advisable therefore that only the information that is absolutely necessary for the purpose of the social work intervention is recorded. The amount of information that is necessary to record will vary according to the field of social work practice. This information should be clear, detailed and relevant to the practice area. Social work is a complex profession practiced in an evolving context. The complexity has led to increased specialization and greater diversity. The theoretical knowledge base that informs social work continues to expand and social workers must remain current. There is also an increasing emphasis on prevention, early and brief intervention, and evidence-based practice. Social workers practice in a climate where there are high consumer expectations, a greater concern with liability and an expectation of autonomous practice. High caseloads and limited resources are a current reality. Social work recording is an integral part of working within this environment. Organizational change continues to be a reality in this province. This leads to shifts in the structuring of social, community and health services, which includes the expansion STANDARDS FOR SOCIAL WORK RECORDING 2
and integration of health care. Service delivery within these organizations includes an increased emphasis on specific programming and interdisciplinary team work where social workers play a key role. Therefore it is important that social workers have access to clear standards for social work recording in these practice settings. Technology continues to influence social work practice as many social work records are computerized and able to be accessed on a broader level within organizations. Email and fax correspondence may form part of the record. There is a broader cultural context of sharing information and rapid transmission of information. It is important that social workers inform clients about the limits to confidentiality in these forms of communication and to advocate for workplace polices to address these concerns. These recording standards acknowledge that social workers have a responsibility for documenting interventions with clients and client systems, and assert that this is an integral part of professional practice. These standards refer to the recording of social work information whether that recording is via electronic or paper means. WHAT IS SOCIAL WORK RECORDING? The Social Work Dictionary (1995) defines recording as The process of putting in writing and keeping on file relevant information about the client; the problem; the prognosis; the intervention; the progress of treatment; the social, economic, and health factors contributing to the situation and the procedures for termination or referral (p. 317). The social work record should also emphasize the client s strengths and solutions for change. The dictionary acknowledges that there are many types of social work recording and the type used may depend upon factors such as agency requirements, the social worker s theoretical base, style and type of intervention. Kagle (1991), describes that social work records Individualize and typify the client, the need, the situation and the service transaction. Link goals, plans and activities to the assessment of the client-needsituation and to the resources available. Facilitate the delivery of services to or on behalf of the client. Through the process of making the record, which involves reviewing, selecting, analyzing and organizing information; and through the product, the record, itself, which becomes an important resource in communication about the case (p. 1). Therefore, the purpose of social work recording is to provide: STANDARDS FOR SOCIAL WORK RECORDING 3
Accountability to the client, the organization and to relevant legislation Evidence of facts gathered, assessment, intervention and outcome On-going essential information A clear statement of social work involvement on an on-going basis Relevant information for future social work involvement and continuity of care. Information about the role of social work in an interdisciplinary team Documentation for the purposes of research and program evaluation STANDARDS FOR SOCIAL WORK RECORDING (ELABORATED) Standard 1 Documentation of social work interventions with clients are contained in one written record (or master file) as per the Canadian Association of Social Workers Code of Ethics. Social workers are required to maintain records on all clients or client systems within that one written record. The one written record can be electronic, paper or both, depending on the agency s policies and procedures. When client records are shared across professions or agencies, social work documentation should only include information that addresses the clients needs and meets the requirements of the employer. In such instances, social workers should not maintain client information that is not documented in the master file. Essentially, this means that information about clients should not be stored in separate files that are not part of the master file. Clients and client systems should be informed that this information is being recorded and who will have access to this information. Social workers should also be aware of agency policies and legislation that allows clients the right to view professional records and appropriate appeal processes. This highlights the importance of receiving informed consent from clients prior to intervention. The CASW Standards of Practice (1995) outline the following requirements for the social work file. Identifying information Source and nature of referral Date and place of initial and subsequent contacts Name and qualification of the social worker Plan and nature of professional services provided Outcome of intervention and recommendations Documentation received from client or from third parties about the client STANDARDS FOR SOCIAL WORK RECORDING 4
Consents, releases or authorizations pertaining to the intervention or to the communication or information about the client It is also important to emphasize that social work assessments should be included in the client file. Standard 2 Confidentiality is an important element in social work recording. Clients, families, groups and communities are made aware of the limits to confidentiality before initiating the social work relationship and throughout the relationship as needed. When social workers provide services to more than one individual in a client system (i.e., families, couples and groups), it is important that all parties are informed of each person s right to confidentiality and the confidentiality of information shared by others. According to the CASW (2005) Code of Ethics, it is essential that social workers protect the confidentiality of third party information when providing clients with access to records. According to the CASW Code of Ethics (2005), it is important that social workers take reasonable steps to ensure that clients records are stored in a secure location and that clients records are not available to others who are not authorized to have access. Within the current context of technological advances, it is important that social workers take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephone answering machines and other electronic technology. Social workers should also inform clients of the limits to confidentiality that may apply to these forms of communication. Social work research and education is an integral part of practice. Research is often conducted on both a formal and informal basis. Case recordings and social work documentation can only be used for educational or research purposes if consent from the client or client system is obtained. Standard 3 Assessment is the foundation of social work documentation. Assessments are based upon facts that should be clearly documented. Only facts that are clearly relevant to the assessment and planned intervention should be recorded. According to Hepworth & Larsen (1990), as cited in Jordan & Franklin (1995), social work assessment is defined as STANDARDS FOR SOCIAL WORK RECORDING 5
The process of gathering, analyzing, and synthesizing salient data into a formulation that encompasses the following vital dimensions: 1) the nature of the clients problems, including special attention to the roles that clients and significant others play in the difficulties, 2) the functioning (strengths, limitations, personality assets, and deficiencies) of clients and significant others, 3) the motivation of clients to work on the problems, 4) the relevant environmental factors that contribute to the problem, and 5) the resources that are available or needed. According to the CASW Code of Ethics (2005), social workers should only document essential and relevant details which are relevant to the clients situation and delivery of services. All professional opinions need to be backed up with facts. Standard 4 Social work documentation must be in a format that facilitates monitoring and evaluation of the social work intervention. This means that recordings should be completed in a timely and chronological order, and be free from jargon, including emotive or derogatory language. The recordings should not have any omissions, however if there are any corrections to be made, they should be initialed by the social worker and dated. When using abbreviations, it is also important to indicate what these stand for. Consultations with a supervisor, colleague, or outside consultant should also be documented in the client s record. Informed consent of the client is necessary when seeking consultation from an outside consultant or third party. Any information about a client whether in the official file or in the form of jot notes is considered part of the file and is subject to the same standards. Keeping jot notes/working notes, separate from the master file, are strongly discouraged. Standard 5 Outcomes are important. Social work documentation requires a plan and the termination of the social work relationship should be clearly documented. It is important that the social work record clearly identify the services to be provided, and the client goals for intervention. In interventions with clients, social workers often face ethical dilemmas. An ethical dilemma occurs when social workers need to choose between two competing values (i.e. confidentiality and duty to protect). It is important that social workers clearly document the ethical decision-making process that they follow when resolving ethical dilemmas. This information should be recorded in the client record. STANDARDS FOR SOCIAL WORK RECORDING 6
Standard 6 Policies should be developed to ensure timely recording and auditing of social work documentation that is consistent with agency standards. In situations where polices are not in place to allow for social work recording in a timely manner, the social worker shall advocate for such policies. Standard 7 Documentation of community development processes, project planning, policy development, and research is grounded in the values, ethics, and philosophy of the profession and reflects adherence to the Canadian Association of Social Workers (CASW) Code of Ethics and the Canadian Association of Social Workers (CASW) Standards of Practice. It is imperative that social workers employed in community organizations and consulting work, including social work managers, document their work with clients, families, groups, communities, employers and stakeholders in accordance with the standards set forth in this document and the CASW Code of Ethics and Standards of Practice. STANDARDS FOR SOCIAL WORK RECORDING 7
APPENDIX A Summary of Federal and Provincial Privacy Legislations At the federal level, the Privacy Act has been developed to protect the privacy of information and provide a record of access to information held by government institutions, and the Personal Information and Electronic Documents Act (PIPEDA) addresses the protection information held by the private sector. At the provincial level, the Access to Information and Privacy Act makes public bodies more accountable by giving the public a right to access records, giving individual s a right to correct information about themselves, specifying limited exceptions, preventing the unauthorized collection use or disclosure of personal information and providing for an independent review of decisions made by the public bodies. STANDARDS FOR SOCIAL WORK RECORDING 8
REFERENCES Access to Information & Protection of Privacy Act (2004). Government of Newfoundland and Labrador: Queen s Printer. Retrieved Nov., 2004 from website www.hoa.gov.nl.ca/hoa/statutes/a01-1.htm. Barker, R.L. (1995). The Social Work Dictionary (3 rd edition). Washington, DC: NASW Press. Canadian Association of Social Workers, (CASW) (2005). Code of Ethics. Ottawa: CASW. Canadian Association of Social Workers (CASW) (1995). Standards of Practice. Ottawa: CASW. Doner Kagle, J. (1984) Restoring the clinical record. Social Work, 29(1), 46-50. Doner Kagle, J. (1991). Social Work Records (2 nd ed.). Belmont, Calif.: Wadsworth Publishing Company. Doner Kagle, J. (1993) Record keeping: Directions for the 1990s. Social Work, 28(2), 190-196. Doner Kagle, J. (1995). Recording. Encyclopedia of Social Work (19 th ed.). Washington, DC: NASW Press. Gelman, S.R., Pollack, D., Weiner, A. (1999). Confidentiality of social work records in the computer age. Social Work, 44(3). Jordan, C., & Franklin, C. (1995). Clinical Assessment for Social Workers. Chicago, Illinois: Lyceum Books, INC. Ontario Association of Social Workers. (1999). OASW Guidelines for Social Work Record- Keeping. Ontario: Author. Ordre Professionnel Des Travailleurs Sociaux du Quebec. (1996). Record Keeping Standards for Social Workers. Quebec: Author. Personal Information Protection and Electronic Documents Act (2000). Department of Justice. Retrieved Dec., 2004 from website http://laws.justice.gc.ca/en/p-8.6/93196.html. Privacy Act (1985). Department of Justice. Retrieved March 6 th, 2003 from website http://laws.justice.gc.ca/en/p-21/93445.html. STANDARDS FOR SOCIAL WORK RECORDING 9
Reamer, F. (1998). Ethical standards in social work: A critical review of the NASW code of ethics. Washington, DC: NASW Press. Tebb, S. (1991). Client-focused recording: Linking theory and practice. Families in Society: The Journal of Contemporary Human Services, 72(7), 425-432. Wilczynski, B. L. (1981). New life for recording: Involving the client. Social Work, 26(4), 313-317. STANDARDS FOR SOCIAL WORK RECORDING 10
ACKNOWLEDGEMENTS The following individuals have made a significant contribution to the development of these standards Judy Paul, M.S.W., R.S.W. Joan Davis-Whelan, M.S.W., R.S.W. Lisa Crockwell, M.S.W., R.S.W. Patti Erving, M.S.W., R.S.W Michelle Ryan, M.S.W., R.S.W Annette Johns, B.S.W., R.S.W The Newfoundland and Labrador Association of Social Workers would like to thank the many individuals and professional practice councils for their review and input. STANDARDS FOR SOCIAL WORK RECORDING 11