About the Importance of Documentation Skill in Social Work

1. SUBMITTED BY,
SHABNA A A
MSW FIRST SEMESTER
VIMALA COLLEGE (AUTONOMOUS)
THRISSUR
TOPIC: IMPORTANCE OF DOCUMENTATION
SKILLS IN SOCIAL WORK

2. CONTENTS
 Introduction
 Importance of documentation skill in social work
 Recording
 Conclusions
 References

3. INTRODUCTION
 Documentation is an essential component of good social work
practice.
 The social worker viewed as a mechanism to facilitate theory
building, research, and teaching.
 it is a tool to protect clients and to protect practitioners in the event
of an ethics complaint or lawsuit.

4. IMPORTANCE OF DOCUMENTATION SKILLS IN
PROFESSIONAL SOCIAL WORK
 The process of preparing documentation focuses the assessment and
understanding of the client’s goals.
 It provides the starting point with the client for subsequent intervention
and serves as a method of evaluation for the intervention.
 Good documentation is a key to establish accountability and evidence of
the services provided.
 The process of documentation is useful for risk management purposes
in supervision, management, and administration.

5. FUNCTIONS OF DOCUMENTATION
 Assessment and planning
 A clear and comprehensive documentation of all case-related facts and
circumstances is essential.
 It ensures that social workers have an adequate foundation for their
clinical reasoning and intervention plans.
 The data provide a reliable source of measuring performance and
outcomes.
 Incomplete records may lead to inadequate planning and intervention,
critical judgement errors, and poor outcomes for clients.

6. Continuation....
 Service delivery
 Records are necessary for competent delivery of clinical, community-
based, and agency-based services and interventions.
 Continuity and coordination of services
 Documentation facilitates professional and interdisciplinary
collaboration and coordination of services.

7. Continuation....
 Supervision
 Supervisors, as well as administrators and agencies, can be held liable
for the errors and omissions of their staff if there is evidence of flawed
supervision.
 Social work supervisors needs to carefully document the supervision
they provide.

8. Continuation....
 Service evaluation
 Facilitating clinical evaluation in individual cases, records also provide
essential data for broader program evaluations.
 Accountability
 Social workers should to include details about the services they provide,
the meetings they attend, the supervision they offer, and the consultation
they obtain.
 These new demands clearly illustrate the fit of documentation for
accountability purposes.

9. ROLE OF SOCIAL WORKER IN DOCUMENTATION
 According to NASW code of ethics, it is the ethical duty to document
the services provide, client’s right to view their records, and social
worker’s duty to protect client’s records from unauthorized access or
use.
 Social work is a diverse profession meaning that the specifics of the
record will be determined by the area of practice and the nature the
intervention.
 Social workers should aware the importance of documentation,
systematic and individual barriers

10. Continuation....
 Identifying and addressing these barriers are significant steps towards
ensuring high quality professional documentation.
 Documentation is an essential skill within social work and can be an
intervention in its own right.

11. PRINCIPLES OF DOCUMENTATION
 The document should be liable and ensure appropriate content in
documentation, the social worker should consider such issues.
 The content must have a careful line, striking a balance between too
much and too little information.
 The contents of the documents should be kept confidential
 Objectivity, accuracy, simplicity and brevity should be the guiding
factors in preparing records
 It should be written in very simple language and a simple type and
Abbreviations should be avoided

12. RECORDING
 According to The Social Work Dictionary (2014) defines recording as
the “the process of putting in writing and keeping on file relevant
information about the client, the problem, the prognosis, the
intervention plan, the progress of treatment, the social, economic and
health factors that contribute to the situation and the procedures for
termination or referral.”
 The social worker wants to interview the client and details should be
recorded in a way that recalls the particular client with all his/ her
individual differences.

13. PURPOSES OF RECORDING
 Documentation of social work activity
 Case records provide an ongoing picture of the nature of social work
involvement with the client, progress in achieving social work goals
and outcome.
 Continuity of service
 When a client contacts the social work agency, the service is provided
by the entire setting. In case an individual staff member is not available
in the agency must be able to pick up where he or she left off. This
would be possible with the help of record only.

14. Continuation....
 Quality control:
 The quality and quantity of services being provided could be known by
reviewing written records that present a picture of social work activity.
 Statistical reporting
 Case records are periodically used by social work agencies as sources
of data to justify agency’s activities, to seek and maintain funding, to
substantiate the need for additional staff or to do programme planning.

15. Continuation....
 Organising the worker’s thoughts
 Recording provides factual data and observations, which could lead to
more in-depth diagnostic assessment and treatment planning
 Inter-disciplinary communication
 Recording is a means to communicate social-diagnostic information
and recommendations for consideration by other professionals who
may be involved with the client in a team approach to treatment.

16. Continuation....
 Teaching and research
 Properly maintained case records could be a mechanism for mutual
assessment of practice skills and the teaching of new or refined
techniques.
 A therapeutic tool:
 Recording can be used as a therapeutic tool with the client to help him
to respond to treatment.

17. TYPES OF RECORDING
PROCESS RECORDING
 Is a specialised and highly detailed form of recording.
 Everything that takes place during a client in contact, including the
worker’s feelings and thinking is noted down.
 It is especially useful to the social worker striving to further develop
understanding and skill in difficult situations or in situations in which
the worker is developing new skills.

18. SUMMARY RECORDING
 It includes entry data, social history, a plan of action, periodic
summaries of significant information, action taken by the worker and a
statement of what was accomplished as the case gets closed.
 Summary records are short and easy to use when considering the total
service process.

19. PROBLEM-ORIENTED RECORDING
 It used in interdisciplinary setting.
 Problem-oriented records contain four parts.
 First, there is a database that contains information pertinent to the client and
work with the client. This includes such things as age, sex, marital status,
functioning limitations, financial situation etc.
 Second is a problem list that includes a statement of initial complaints and
assessment of the concerned staff.
 Third are plans and goals related to each identified problem.
 Fourth are follow-up notes about what was done and the outcome of that
activity.

20. CONCLUSION
 Social work documentation is essential for the client, the social worker
and the organization within which services are provided.
 The documentation within social work practice and provides
considerations for individual social workers and organizations to ensure
the highest quality of services are provided to clients.

21. REFERENCES
 Yogendra Pal (2018), Trueman’s specific series UGC NET/SET Social
work, Danika Publishing company, New Delhi.
 Fredric G. Reamer (2015), Documentation in social work: evolving
ethical and risk-management standards, Faculty publications. Paper
163. http://digitalcommons.ric.edu/facultypublications/163

22. THANK YOU