by Allan Barsky, J.D., MSW, Ph.D.
Social work documentation. Now, how exciting is that?! Yes, documentation is not exactly the most thrilling aspect of social work practice. In fact, sometimes the documentation process can be downright tedious. Still, if you want excitement in your professional life, try documenting in an incompetent, disrespectful, dishonest, incomplete, or disorganized manner. Nothing says “malpractice lawsuit” faster than situations in which social workers provide direct evidence of substandard practice in their client records. Conversely, good old boring records are vital to risk management, reducing the risk of malpractice lawsuits, professional disciplinary hearings, and agency discipline.
Standard 3.04 of the National Association of Social Workers (NASW) Code of Ethics (2008) provides social workers with guidance about documentation and record keeping. Part (a) states that social workers should ensure their documentation is “accurate and reflects the services provided.” That makes sense. Be honest. End of sentence.
Part (b) instructs social workers to include sufficient information to “facilitate delivery of services and to ensure continuity of services provided to clients.” Once again, this standard seems obvious. Records are supposed to support the provision of services. Social workers, supervisors, and colleagues need to know about the client’s concerns, the client’s goals, and the plans for reaching those goals. Good records can keep the helping professionals and clients on track, and ensure that services are provided in a competent and effective manner. For these purposes, comprehensive, and perhaps expansive record keeping might be suggested. Isn’t it better to have more than enough information, rather than not enough?
Part (c), however, suggests that “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.” Ah, there’s the rub. More is not always better. Given that clients have a right to privacy, documentation should be limited to what is relevant to service delivery. Even though most client records are “confidential,” there are many people within the agency and beyond who could have access to all or parts of the records:
- Supervisors and co-workers
- Researchers and program evaluators
- Government auditors or other officials responsible for monitoring and accountability
- Insurance providers
- Other agencies or people as authorized by client consent
In addition, client records may be used in courts under various circumstances—for instance, in child protection cases, in family law cases, in malpractice lawsuits, and in mental health hearings. To protect client privacy, social workers should consider limiting what they document, so as not to embarrass clients or share information that clients may want to remain private.
“So,” you may be asking, “how do I balance the need to provide full and accurate information in client records with the interest of protecting client confidentiality?” I’m glad you’ve asked. To address this balancing act, consider the following factors: laws, agency policies, client wishes, and social worker needs.
First, various statutes and regulations may govern your practice, including what information needs to be recorded, how records should be maintained, client rights to access records, and under what circumstances confidential records may be shared with others. At a federal level, consider the Health Insurance Portability and Accountability Act (for health settings) and Federal Education Rights and Privacy Act (for educational settings). At a state level, there are specific laws regulating child protection, criminal justice, mental health, and other practice settings. At a minimum, records should meet these standards. For instance, when requesting reimbursement for services provided under Medicaid, consult the laws governing Medicaid.
In addition to laws, agency policies also govern what type of information needs to be gathered—for instance, date of contact, purpose of meeting, client concerns, and information related to safety (child or elder abuse and neglect, suicidal or homicidal ideation, drug use, or intimate partner abuse). Note that when laws and agency policies conflict, laws generally take precedence. For example, an agency policy may require gathering client Social Security numbers, while a state law may prohibit this. Follow the law—and change agency policy to comply. Agencies often provide specific forms (digitally or on paper) requiring social workers to gather and document particular information as part of their intake, assessment, intervention, and evaluation processes. Although it is important to follow the law and agency policies, these are far from the only considerations.
Standard 1.02 of the NASW Code reminds us that clients have a right to self-determination. Ideally, this right includes the ability to provide input into what types of information are gathered and documented by the social worker. Consider a client who is having extramarital relations, but does not want this information documented. Alternatively, consider a client from another country who does not want you to document that she is working without a proper visa. Does the law require you to document this information? Does agency policy require such documentation? Is this information relevant to the services you are providing? Is there a way that you and the client reach agreement about how to handle these sensitive issues in an ethical manner, meeting both client wishes and your professional obligations?
As a social worker, consider what needs to be documented for you to provide safe and effective services. If you have many clients, records help you keep track of the work you are doing with each. They also allow colleagues and supervisors to follow up with a client if you take ill or are not available for other reasons. In some instances, clients may return to services after many months or years. Records allow you to refresh your memory and ensure that new services take prior assessments and experience into account.
I have worked with agencies that have no documentation for clients. I have worked with agencies that have kept complete videos of all social work-client interactions, to maintain a full record of all communications and interactions. Each of these situations had reasonable ethical justifications for its approach. Some agencies that provide outreach to survivors of state torture, for instance, do not maintain documentation about the individual clients they serve. These clients have been traumatized and may not engage with any helpers who collect and record personal information. To build trust, outreach workers forgo consent forms, progress notes, and formal assessments. They may document the number of clients served and the types of services offered, but they do not maintain any identifying information. In contrast, some forensic social workers use video to ensure that they have a complete record of the information they are gathering, as well as the process used to collect the information. If their forensic evaluations are questioned in court, they are able to produce the videos. Most agencies fall somewhere between these extremes. In these situations, social workers need to make choices about what is legally required to be documented, what is important to document, how to respect client wishes, and how to respect client privacy.
When in doubt about what to document, consult your supervisor or another trusted professional. As a general guide, do not put anything in your case records that you would not want a client to see. In most practice settings, clients have a right to see their records, as well as to request changes. And finally, find ways to document what is important in an honest and efficient manner. Social workers and their agencies can take the tedium out of record-keeping by streamlining the process, using mobile technology (where appropriate), and avoiding documentation of information that does not advance the helping process.
Dr. Allan Barsky is Professor of Social Work at Florida Atlantic University and former Chair of the National Ethics Committee of the National Association of Social Workers. He is the author of Ethics and Values in Social Work (Oxford University Press), Conflict Resolution for the Helping Professions (Oxford University Press), and Clinicians in Court (Guilford Press). The views expressed in this article do not necessarily reflect the views of any of the organizations with which Dr. Barsky is affiliated.