This document outlines the importance of thorough documentation when providing social work services. It discusses how documentation provides: 1) A record that will be reviewed by legal and medical professionals as the official account of decisions made and services provided. 2) A historical baseline to measure outcomes and assess what has and has not worked for the client. 3) Context and background for future workers to understand the client's needs and history of services. Social workers should ensure documentation is accurate, reflects the services provided, and protects client privacy, while including necessary details to facilitate continuity of care.

1. Leaving the trail in the sand

2. • Protection
• Gives rationale behind decision making.
• Will be the official record reviewed by judges, attorneys, etc.
• Becomes historical baseline to measure outcomes
against.
• Historical record of what has, and has not, worked for this
client.
• Ensures the best provision of service to our client.
• Information for coverage workers.
• Informs you/your supervisor of the focus, needed changes, and
status
• Gives a context and a starting point for the next worker.
Delivery of service proof for billing purposes!

3. • 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.

4. • Always consider the case record to be a legal document
that will be reviewed by other professionals.
• Follow the guidelines found in your policy/practice
manuals (Section 16, APS Procedure Manual).
• Document all significant/important events. (So what?
Test)
• Document what you intend to do (or did), or how you
intend to follow up in regards to what you found. Then
document that follow up.
• Document in the first person, in the present tense.

5. • Misspelled words, poor grammar, confusing structure
(review it!)
• Non standard abbreviations or jargon.
• Conclusions without sufficient foundation. (i.e., the client
was lying/angry/out of it.)
• Negative, biased, prejudicial or inflammatory language.
• HIV status
• Unverified, salacious intimate details that are not
pertinent to the case.
• The Case Record is not the place to document
disagreements with your supervisor, another agency, or
the larger flawed system.

6. • Your written record is your representation of your
professional self to the larger world.
• Many people will only see that written record and form
their opinions of you, your work, and your agency based
on that written presentation.

7. The Oasis in the Desert

8. • AMHI consent decree members must be visited, at least,
once a month when stable or twice a month when
hospitalized or unstable.
• Non-consent decree clients must be visited, at least,
quarterly.
• Investigation clients must be seen at least once per the
investigation timetable, and as many additional times as
necessary to resolve the investigation.
• If additional allegations of abuse, neglect or exploitation
are received regarding a client under guardianship, you
will need to see them per the investigation timetables.
(See your supervisor)

9. • Case aides, where available, can assist in seeing clients
but may not make more than one consecutive visit to
each client.
• Best practice is to see clients in each of their
environments. (i.e. home, day program, clubhouse, etc.)
• Utilize this time to gather other information from service
providers, the chart, etc.
• Do no harm! If a client is ill or very escalated, do not
force contact. Lay eyes on the client, gather info from
other sources or reschedule.
• On each visit, assess safety, well-being and
appropriateness of placement/services.

10. • Review the note of your last contact. Are there things
you promised to do/get/find out prior to this contact?
• Review the Case Plan/MCFVRE with the client to gain a
full picture of the client’s needs, wants, and best
interests.
• Review the case for needed paperwork. Are there
releases needed or other items that need to be done
now?
• Return related phone calls or respond to other requests
prior to the visit so you have all the relevant information.
• Take your time! This client at this time is the focus and
purpose of your job. She/he is the reason for your
existence and the best part of the job, act accordingly.