the writer’s handbook: a guide for social workers chapter 2 documentation and forms by marsheila...

The Writer’s Handbook: A Guide for Social

Workers

Chapter 2

Documentation and Forms

By Marsheila Harris, MSW, Indiana University Northwest

©2014 The Writer’s Toolkit, Inc. All Rights Reserved.

If it is not written, it did not happen.

In social work, this saying speaks to the urgency of maintaining strong documentation in the field.

Social workers must submit well-written forms and documents for the agency and for external service providers and collaborators.

Reports are routinely sent to the courts, medical community, criminal justice departments, and other agencies as part of a case file that serves as an official document.

The reports are used to assist in decision making for the client’s well-being and to provide services or resources.

National Association of Social Workers (NASW)

The NASW Code of Ethics are at the core of

social work, providing guidance to social

workers about commitment to clients,

confidentiality, and professionalism.

The NASW Code of Ethics articulates basic

values, ethical principles, and ethical

standards to guide social workers’ conduct.

NASW Code of Ethics

The National Association of Social Workers Code of

Ethics also addresses the need for accurate and

professional documentation (2008).

To view the entire code, go to the NASW website:

http://www.socialworkers.org/pubs/code/code.asp

Let’s take a look at some parts of the code that relate to

documentation.

1.07. Privacy and Confidentiality

a. Social workers should respect clients’ right to

privacy . . . and not solicit private information unless

it is essential to providing services or conducting

social work evaluation or research. Once private

information is shared, standards of confidentiality

apply.

b. Social workers may disclose confidential information

when appropriate with valid consent from a client or

a person legally authorized to consent on behalf of a

client.

c. Social workers should protect the confidentiality of

all information obtained in the course of professional

service, except for compelling professional reasons .

. . only information that is directly relevant to the

purpose for which the disclosure is made should be

revealed.

d. Social workers should inform clients, to the extent

possible, about the disclosure of confidential

information and the potential consequences . . . .

3.04 Client Records

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.

c. Social workers’ documentation should protect

clients’ privacy to the extent that is possible and

appropriate and should include only information

that is directly relevant to the delivery of services.

d. Social workers should store records following the

termination of services to ensure reasonable

future access. Records should be maintained for

the number of years required by state statutes or

relevant contracts.

1.12 Derogatory Language

Social workers should not use derogatory

language . . . . Social workers should use accurate

and respectful language in all communications to

and about clients.

NASW Press Guidelines for Describing People (2011)

The purposes of the guidelines are to help authorsportray people as accurately and vividly as

possibleeliminate bias from their writingincorporate the richness of cultural diversityuse language that is accessible and inviting to the

reader.

NASW Press Guidelines

Seek and use the preference of the people you write about.Ask people how they prefer to be described

Be as specific as possible.

Whenever possible, use specific racial or ethnic identities instead of collecting different groups under a general heading, such as Hispanics.

Cite actual ages rather than using a term such as older people or senior citizens.

Describe people in the positive.

Describe people for what they are rather than what they are not; do not use terms such as nonwhite or nonparticipant.

Help the reader see that you are writing about

people, not subjects or objects.

Use the terms sample or subject for statistics and describe participants as respondents, participants, workers, and so forth.

Avoid using terms that label people.

When adjectives that describe a person's

condition or status are used as nouns, they

become labels that often connote a

derogatory intent.

People who have lived a long time become the

elderly or the aged; if you cannot use specific

ages or age ranges, use terms such as elders or

older people.

Using “the” in front of a noun is a sign that you may be using a label.

Labels Revised

the disabled people with disabilities

the handicapped people with disabilities

the blind people who are blind

the lower class people who are poor

the upper class people with high incomes

the disadvantaged people who have disadvantages

Use gender-neutral language.

Outdated Current

policemen police officers

housewife homemaker

mailman mail carrier

fireman firefighter

chairman chairperson

salesman sales representative

Can you think of more examples?

Use plural nouns to avoid singular, gender-specific pronouns.

Gender biased:

A social worker should consider his mission . . .

A social worker should consider her mission . . .

Incorrect:

A social worker should consider their mission . . .

Revised:

Social workers should consider their mission . . .

More Examples

Poor Usage Revised

schizophrenics people diagnosed with schizophrenia

challenged people with challenges

wheelchair-bound uses a wheelchair

AIDS victims people with AIDS

high-risk groups high-risk behavior

minority racial and ethnic groups

tribes people or nations

blacks black people

nonwhites specific population

Hispanic Cuban Americans, Mexican Americans,

Puerto Ricans

You will find the NASW Press Guidelines for

Describing People in their entirety at the following:

https://www.naswpress.org/authors/guidelines/08c-

tools.html

The guidelines are also posted at your text’s website:

www.thewriterstoolkit.com

Click on the Social Work Resources tab.

Documentation in the Field

Court Summaries

Social Histories

Client Intake Forms

Treatment Plans

Case Notes

Case Notes

Case notes are professional records of the case worker’s interaction with the client, providing a documentation of what was discussed, agreed upon, or unresolved.

Case notes serve as proof of the case worker’s contact and whether or not the client is compliant with services.

Case notes have moved from being handwritten to being completed using a computerized template.

Case Notes

Client Name:ID No. Date of BirthCase Worker Name:

Date of Interaction:

Case Notes:

Questions

Throughout your process:Separate composing from editing