Documentation

Question 1

What are the principles of case recording, documentation & management of practice records?

Answer 1

• Lack of clear documentation can harm clients and hold SW and/or agency liable for malpractice, negligence, breach of confidentiality
  
  • Should only include information directly relevant to delivery of services
  • Release of storage of case recordings also critical
  • SW must ensure that records are not released without proper consent and ensure they are properly stored during and following services
    Should be kept for # of years required by state statutes and regulations & relevant contracts

Question 2

Documentation should be:

Answer 2

• A clear, accurate and unbiased representation of facts
  
  • Written record of all decisions
  • Free of value judgements & subjective comments
    Timely

Question 3

What are some elements of reports?

Answer 3

• Increasingly becoming electronic
  
  • Psychotherapy notes should be kept in a secure location outside of client files to provide added confidentiality protection
  • Agency policies imposed by funders often dictate organizational structure for client files
    ○ Regardless files should be up to date, complete and in a format that makes locating information easy
  • Poorly written reports or inclusion of irrelevant/inappropriate information can adversely impact the client
  • Must develop reports as requested/needed
  • Must be simple enough that they can be understood by a wide range of educational backgrounds and literacy levels
  • Should avoid irrelevant and inappropriate information, meaningless phrases, slang, illogical conclusions
  • SW competence and value of services often judged on written reports
  • Admin reports provide data and accountability to public - # of people served, services delivered, how funds were allocated (can find unmet needs)
    May need to prepare grant reports, evaluations, program proposals & accreditation reports

Question 4

What are the typical sections of reports?

Answer 4

1. Demographic information & intake materials
   2. Assessments, quarterly reviews & reassessments
   3. Service plans with goals
   4. Discharge plans
   5. Releases of Information & referrals
   6. Correspondence

Question 5

What are the principles & processes of developing formal documentS?

Answer 5

• All work is undermined by poor recording/documentation
  
  • Good documentation begins with planning - what is the reports purpose & key content
  • Time must be allotted to be able to do critical analysis - easy to describe, more difficult to indicate significance
    Should know when communication is privileged

Question 6

What are the principles & features of objective & subjective data?

Answer 6

• Ex. In assessment - know facts (objective data) related to client’s situation but also how they are perceived by the client (subjective)
  Not objective facts that determine if the event was traumatic but the subjective emotional experience of the event

Question 7

Treatment plans in healthcare often use SOAP based on subjective & objective data, what does SOAP stand for?

Answer 7

Subjective: client’s report of how they have been doing since the last visit/what brought them into treatment
Objective: Vital signs, physical examinations, lab tests. (in other settings, legal issues, grades etc.)
Assessment: Objective & subjective findings are consolidated into an assessment
Plan: Includes what will be done as a result of the assessment

In evaluation, subjective reports of client with objective indicators of progress should be used to determine when goals have been met & new ones should be set