7/26/2019 Guidelines for Social Work Case Management Documentation

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Guidelines for Social Work Case Management Documentation

What does the NASW Code of Ethics Say?

3.! Client "ecords

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 toensure 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.

General #rofessional Guidelines

Consider case management record to be a legal and/or medical document

ocumentation follows the agency/organi!ation/state or other governing body protocols and these are followed in the

charting. "here may be differences in states# know state requirements.

ocumentation reflects any significant client$ family or ancillary service provider contact

ocumentation is sufficiently detailed and organi!ed to enable another social worker to assume work with the client at any

time.

o not leave blanks# write %/& or not applicable(

)ark any error with a single line and initials * never use correction fluid or tape

&lways explain to client documentation process and share with client when possible/appropriate consider cultural concerns

and history in response to +secrecy+ of documentation(

$i%s and Suggestions

,ighlight the client-s strengths$ supports and coping mechanisms

se a professional writing style avoiding argon$ using shorter words with precise meanings$ writing short paragraphs

focused on a single concept

o not ust report facts as you have been told. 0nstead$ specify where the information came from client reports/states$ client

is diagnosed with,)

Remember to report negative absent( as well as positive present( observations/information/findings

1ach page should have client-s name or identification and include a confidentiality notice

se Clinicians Thesaurusor other documentation resource. R1& R1& R1& * read other professional-s progress/case

notes.

7/26/2019 Guidelines for Social Work Case Management Documentation

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What to a&oid

%ever use your own or casual abbreviations use medical abbreviations(

o not take shortcuts at the cost of clarity

o not use generali!ations or over2interpretations

S3144 C,1C56...this is your integrity6

o not use argon

o not diagnose if the client does not have a clinical diagnosis client is depressed$ rather say client states that he is having

feelings of sadnessor depressed mood(. 7R describe symptoms client describes seeing hallucinationsor is feeling sad on a

daily basis(

o not make recommendations without backing of facts and reason

'nitial 'ntake or Assessment Note

o Completed documentation within 89 hours of meeting and supporting documentation should be included within :;days i.e proof of income(.

o 0ncludes introduction of social work case manager/program role and purpose

o 0ncludes client rights and responsibilities and grievance mechanism

o Client should receive a copy of any work completed together and signed

o 0ncludes$ but is not limited to@> of >@>

TE telephone, HF E Home Fisit, %F E %gency Fisit, !E !ail, CC E Collateral Contact, 0 >>>>> E 0ther