module 20 social case work recording: structure & content...

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SWE/WIF/SCWR/M20 by Mr. Antony Sagayaraj

Module 20

Social Case Work Recording:

Structure & Content of Case Work records, and Use of records

Component 1A

Component 1B

Role Name Affiliation

Principal Investigator Dr. Geeta Balakrishnan College of Social Work, Nirmala Niketan, Mumbai

Paper Coordinator Prof. Xavier Kanickairaj National Institute of Social Work and Social Sciences, Bhubaneswar

Content Writer Mr. Antony Sagayaraj Loyola College, Chennai

Content Reviewer Prof. Xavier Kanickairaj National Institute of Social Work and Social Sciences, Bhubaneswar

Language Editor Ms. Marianne Claudia Rayer Research scholar, Pondicherry University, Pondicherry

Description of Module

Subject Name Social Work Education Paper Name Working With Individuals And Families Module Name Social Case Work Recording

Structure & Content of Case Work records, and Use of records Module ID SW/SCW/20 Pre Requisites Not applicable Objectives • know the meaning of recording,

• gain an insight into the purpose of recording,

• understand the need for recording and its Principles, and

• comprehend the different dimensions of recording.

Key words Recording, Accuracy, Objectivity, Simplicity, Clarity and Brevity

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Quadrant 1

Introduction In social casework practice, recording is defined as the process of writing down relevant information

in a systematic manner about the person who has come to the agency seeking some help. The

information is about the person, his or her problem, the social, economic, and health factors

contributing to the situation of the person, the prognosis, the type of intervention, the progress of the

intervention, and the procedures for termination or referral.

Social casework practice involves many types of recording depending upon factors such as

requirements of the agency, the theoretical perspective of the caseworker, the type of intervention, and

so on.

Objectives

• To know the meaning of recording,

• To gain an insight into the purpose of recording,

• To understand the need for recording and its Principles, and

• To comprehend the different dimensions of recording.

Recording is a written summary of the process of casework. The records of individuals are legally

protected, except under special circumstances. Records allow case workers an opportunity to

document their work with individuals and afford legal protection against suits, as they can show that

caseworkers had followed an intervention plan based on an appropriate assessment. Recording is

important as it publicizes the efficiency of the services. Facts have to be gathered, organized, and

recorded for measurement of results. In the process of giving assistance to an individual there is also a

need to record and document the proceedings for further follow-up and cross verification.

Need for recording

There are compelling reasons to keep good records. Recording is an important and integral part of the

case work procedure and is an output of the activity of the case work. The importance of recording

lies in both the process as well as the product. As recording and documentation is part of every

profession , case work recording is an inevitable part of the case work process. The demands of

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recording go along with the pressing demands of accountability and documentation in any

profession.

Principles of Recording There are some guiding principles for maintaining a good record. However there is no such thing as

an ideal or model record. A record is a flexible instrument, which should be adapted to the needs of

the case. Each case is different, the conditions of work have marked differences and the recording

therefore rests not on following an outline, but in the mastery of certain component processes.

o Accuracy, objectivity, simplicity, clarity and brevity should be observed in writing

records.

o Facts and their interpretation should be distinguished between, as that leads to real

objectivity of the subject matter. The outcome should be drawn in a balanced

manner without attempting to influence the judgment of the reader. For example,

frequent fights between the husband and wife might lead the case worker to

interpret that the wife dislikes or hates her husband.

o The record must be orderly in its arrangement. The caseworker should think in

advance what should be included and then set the material out in a logical

sequence.

o The case work records are not meant to be literary masterpieces, therefore they

should be written in simple language and simple style.

o A verbatim quote can sometimes depict a situation much better than a narrative

description. Therefore, wherever possible, the reactions of the individuals should be

recorded in their own words.

o There should be a certain degree of uniformity and standardization as to the form of

observation.

o A record should have readability and visibility and should contain a clear and concise

presentation of the material. For example, content can be organised under topical

headings such as interviews, home visits, and contact contacts.

o To maintain clarity and accuracy, avoid using words that are ambiguous.

o Note-taking, as far as possible, should be done immediately at the end of the

interview and not during the interview.

o It should always be made clear who are involved in the situation, who is addressing

whom and what the sources of information are.

o The details of every significant subject or situation should be given.

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o One should not record the self-evident, the insignificant, the familiar, and the

repetitive.

o Any record should show clearly the nature of the problem presented or the

request made.

Key Purposes of Recording

• Recording helps in effective assessment and intervention of the person with

problem.

• It enables more effective interviewing and intervention in the case work process.

• It helps to contribute to analytical reflection and improvement in case work

practice.

• It is useful for organising and structuring of information and for orderly thinking.

• It refreshes the memory of the worker and increases retrospective understanding.

• It enables better planning for subsequent interviews.

• It ensures continuity if any case worker discontinues the process or comes for the

next session after a long time.

• It helps in measuring or assessing the ability of the agency.

• It helps for future reference of the person with the problem.

• It helps in supervision and training of students in casework practice wherever

appropriate.

• It serves as a resource or teaching material and adds to the body of knowledge of

social work practice.

• It enables students to develop analytical and interpretative skills.

• It is helpful in social research and planning in a particular area.

• It provides statistical data on social problems.

• It may perhaps be relevant to court proceedings or complaints at present or in

future.

Advantages of Record keeping

§ The process of writing records enables the case worker to reflect systematically on what has

occurred and plan for future sessions. In other words, the process of making records enhances

the quality of the case work process.

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§ Records provide the case worker with details such as the names of the people mentioned by

the individual. This frees the case worker to concentrate on issues raised by the individual

rather than recalling the details from one session to another.

§ Systematic record-keeping makes any changes in the individual’s material over a series of

sessions more apparent. The case worker can also show the individual the progress of the

case work process with evidence . § As case workers seek to be professional and credible, they need to develop the record-keeping

practice that supports them in performing their role and meets the public expectations of

quality of service and accountability of any professional. This is regarded as an increasingly

significant reason, which probably explains why most of the case workers around the country

have chosen to keep records.

Maintaining records in the case work process is the universal norm. Nevertheless, there is a minority

of case workers who prefer not to keep records at all or only keep records for some individuals,

usually when seeing individuals in settings that require records.

Although casework recording is a key element in the process of casework practice, some caseworkers

perceive it as a tedious and time consuming task that gets in the way of practice rather than enhancing

it. They express the view that they spend too much time at their desk in writing the records. Some

research into social caseworkers’ attitude and experience of recording revealed the fact that the topic

of recording has created many strong and ambivalent feelings.

a) One needs to ensure that records are both secure and really confidential. For example, some

case workers may work in settings where burglaries are so frequent that it is difficult to

maintain secure records. Community-based services operating out of converted buses or

other forms of mobile premises have to consider the possibility of the theft of the entire case

work premises, including the records.

b) Record-keeping may complicate trust-building with individuals. For example, case workers

working with individuals who are vulnerable to legal prosecution, like female sex workers,

illicit drug users and others, may have to take into account their clients’ fear that the police

or other authorities could seize any records.

c) Record-keeping is time-consuming.

d) Some case workers are opposed to the possibility of individuals acquiring a legal right to see

records kept about them. Therefore, they prefer not to keep records.

e) Some case workers have reservations about creating records which may be demanded by

individuals for use outside the case work relationship in legal actions against others. They

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hope that an absence of records will enable them to concentrate on the therapeutic

relationship without having to consider how that work would be viewed in a court of law.

f) There is lack of training in the practice of recording.

g) There are variable standards in recording practice.

Aspects of Good Recording

Ø Good recording is done with the participation of the person whose record it is.

Ø The views of the person whose record it is should be recorded including whether he

or she has given permission to share information.

Ø The record should be accurate up to date of the process of casework which can be

reviewed periodically and summarized at the end.

Ø It should include the decisions taken during the process and the reasons for these

decisions.

Ø The chronology of significant events should be included in the record.

Ø The facts should be recorded distinctively from the opinions.

Ø Whatever is recorded should be evidence-based and ethical.

Ø The record should mention the assessment as well as the risk assessment.

Ø It should depict a clear and complete picture of care and support given up to date and

the ensuing plan of action towards solving the problem of the person.

Ø The personal profile of the individual should include details such as name, age,

gender, religion, language, region, educational level, and disability, if any, of the

person.

Records and their Preservation

Data protection refers to the set of privacy laws, policies and procedures that aim to minimize

intrusion into one’s privacy.

Once it is decided to keep the records, the existence of the records and the level of security with

which they are protected have to be made known to the individual . There is a strong ethical

argument that the individuals need to know these facts in order to be in control of the

information that they decide to disclose to the case worker. The minimum standards suggest that

the individuals should be informed about the security of the records. There are different kinds of

procedures adopted by the case workers for security. First of all, physical security of the records is of

paramount importance. Locking records in a desk or in a cupboard will prevent casual inspection by

anyone. If there is a foreseen risk of some unauthorized person wanting to access the records ,

then the records have to kept in a safe under lock and key.

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Contents of Casework Records

There are no fixed rules about what must be included in case work/interview records or how they

ought to be written. Case work records that we see vary considerably in style, from brief factual

accounts which focus on what the individual reported to ones that include more of the case worker’s

thoughts and responses. The guiding principle is that the type of record should be one that supports

the therapy and enables it to be delivered with a reasonable standard of care. A good record is written

as closely as possible in time to the events it records. Some case workers set aside ten minutes with

individuals for this purpose. If there is any reason to think that a record might need to be produced for

legal purposes, it is good to distinguish between what was directly observed, what the individual said

and the case worker’s own response or thoughts.

There is no single correct way of writing case work notes. It still appears to be a topic neglected in

basic training. Each case worker has to develop a style that is sufficient to support the case work but

without being excessive in what is recorded.

There are some other items to be included in the record:

o Any written and signed consents to all interventions.

o Any written and signed contents to all passing of confidential information

o All appointments, including non-attendance by the individual

o Intervention contracts

o Up-to-date record of the case worker’s reasoning behind decisions about significant

interventions and general strategies

o Consultations with anyone else about the individual

o Copies of any correspondence from the individual or relating to work with the

individual

o Any instructions given to the individual and whether or not the individual acted on

these.

Matters not to be included in the process of Recording

• Records ought not to include anything that could disrupt the therapy if seen by an individual.

• Prejudice and abusive comments are to be avoided.

• Negative evaluations should only be included if they serve a therapeutic purpose, for

example, a negative counter-transference would be justified if it is integral to the therapy and

is a statement about the case worker’s internal processes, rather than directly ascribed to the

individual .

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Format of Casework Records and their Templates

There are a few components written about how best to structure case work records. There can be two

sections. The first section contains useful background information about the individual and the

contractual terms that case worker and the individual have agreed upon.

Individuals’ records need to be clearly identified so that there can be no confusion regarding

identity, because in large agencies it is not unusual to find two individuals with the same

name. The caseworker might include

• Individual s family name

• Other names

• Date of birth

• Address

• Contact phone numbers

Where hand-written records are kept, it can be an advantage to label each page of the individual

record with the individual’s full name so that the possibility of pages being inadvertently placed in the

wrong file is minimized.

Additional demographic information about the individual, if available, such as Marital status, Name

of the partner or spouse, Names and ages of children, Referral source, and so on could be added.

The notes for each case work session may include Date of the session, Factual information given by

the individual, Details of the individual’s problems, issues, or dilemmas, Notes on the process that

occurred during the session, the outcome of the case work session, the intervention used by the case

worker, any goals identified, any contract between the individual and the case worker, matters to be

considered in subsequent sessions, the counselor’s own feeling about the individual and the case work

process, and the case worker’s initials or signature.

(FORMAT FOR NOTES-TAKING)

Date of the session_______________

Factual information given by the individual______________________________________

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_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Details of the individual’s problems, issues, or dilemmas___________________________

_________________________________________________________________________

_________________________________________________________________________

Notes on the process that occurred during the session______________________________

_________________________________________________________________________

_________________________________________________________________________

Notes on the outcome of the case work session___________________________________

_________________________________________________________________________

_________________________________________________________________________

Notes on the intervention used by the case worker_________________________________

_________________________________________________________________________

_________________________________________________________________________

Notes on any goals identified__________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Notes on any contract between the individual and the case worker___________________________

______________________________________________________________________________

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______________________________________________________________________________

Notes on matters to be considered in subsequent sessions_______________________________

_____________________________________________________________________________

_____________________________________________________________________________

Notes on the counselor’s own feeling about the individual and the case work process___________

____________________________________________________________________________

____________________________________________________________________________

The case worker’s initials or signature____________________________________________

____________________________________________________________________________

____________________________________________________________________________

Responsibility of the caseworker related to informing the client about records and recording

The agency needs to establish and maintain good practices for collection of information from

individuals availing of the caseworker’s service. In this situation, the caseworker needs to

1. Be clear about the agency’s reasons for collecting the information and explain the rationale to

the person.

2. Be ready, with no resistance or surprise, to answer specific queries from individuals about the

details he or she asks for, any forms to be completed or notes he or she makes.

3. Deal with individuals’ questions courteously, even if they ask in an abrupt or confrontational

way. Individuals may feel uneasy about challenging the information systems and this unease

can emerge in an apparently unfriendly way.

4. It is important that the agency commits to the view that individuals have the right to

understand why information is requested.

5. Explain in a straightforward way how the person can access his or her own information, and

the extent to which the information is available to others in the agency.

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In short, Social caseworkers should be open and honest with the person or his or her family

where appropriate, from the beginning about why, what, how and with whom their

information will, or could be shared. They must seek the person's agreement to share their

information, unless it is unsafe or irrelevant to do so.

SUMMARY v In social casework practice, recording is defined as the process of writing down relevant

information in a systematic manner about the person who has come to the agency seeking

some help.

v Social casework practice involves many types of recording depending upon factors such as

requirements of the agency, the theoretical perspective of the caseworker, the type of

intervention, and so on.

v Recording is an important and integral part of the case work procedure and is an output of the

activity of the case work.

v Although there is no such thing as an ideal or model record, there are some guiding principles

for maintaining a good record.

v As case workers seek to be professional and credible, they need to develop the record-keeping

practice that supports them in performing their role and meets the public expectations of

quality of service and accountability of any professional.

v Some case workers have reservations about creating records which may be demanded by

individuals for use outside the case work relationship in legal actions against others. They

hope that an absence of records will enable them to concentrate on the therapeutic

relationship without having to consider how that work would be viewed in a court of law.

v Once it is decided to keep the records, the existence of the records and the level of

security with which they are protected have to be made known to the individual .

v Case work records vary considerably in style, from brief factual accounts which focus on

what the individual reported to ones that include more of the case worker’s thoughts and

responses.

v Records ought not to include anything that could disrupt the therapy if seen by an individual.

Prejudice and abusive comments are to be avoided.

v The agency has to be clear about its reasons for collecting the information and explain the

rationale to the client.

v The caseworker should explain in a straightforward way how the client can access his or her

own information, and the extent to which the information is available to others in the agency.

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