Academic journal article
By Reamer, Frederic G.
Social Work , Vol. 50, No. 4
Throughout social work's history, practitioners have recognized and appreciated the usefulness of recording their encounters with clients (Aptekar, 1960; Frings, 1957; Kagle, 1984,1987, 1991, 1995a; Little, 1949; Timms, 1972; Urbanowski, 1974; Wilson, 1980). Case documentation not only supports the delivery of services to individuals, families, couples, and small groups, but it increasingly has new applications in keeping with the changing environment in which social workers operate. Traditionally, documentation helped practitioners coordinate and evaluate service needs and delivery. More social workers, however, realize the significance of documentation as a liability shield and risk-management tool. This warrants a fresh look at documentation so that practitioners, supervisors, and agencies can apprise themselves of proper documentation techniques, related ethical standards, and the potential pitfalls social workers may face as they shift their practices.
During social work's earliest years, in the early 20th century, discussions about documentation focused almost exclusively on theory building, research, and teaching (Eliot, 1928; Hamilton, 1936, 1946; Richmond, 1925; Sackheim, 1949; Sheffield, 1920; Sytz, 1949). By the 1920s and 1930s, social work's literature emphasized the importance of record keeping when "personality influences, psychological goals, and psychiatric casework were involved" (Pinkus, 1977, p. 1162). By 1940, professional standards had evolved for three distinct types of case records: (1) chronological reports of services provided, (2) summary recordings of practitioners' relationships with clients, and (3) process recordings that provide moment-by-moment details of clients' behavior and interactions between practitioners and clients (Burgess, 1928). Over time social workers refined their recording practices with respect to assessing clients' circumstances, statuses, and needs; documenting more subjective information about clients' circumstances (information provided by the client, family, and significant others); recording objective information based on tests or other independent sources, the social worker's assessment, and plans; and completing standardized forms that summarize client information using short answers or checklists (Kagle, 1987, 1995b).
Until fairly recently, discussions of case recording and documentation focused almost entirely on clinical relevance. That is, the field primarily saw documentation's function as a diagnostic, assessment, planning, and intervention instrument. In the mid-1990s, however, a burgeoning group of social workers began to recognize the relevance of documentation for risk-management purposes. The shift was largely a result of growing awareness that case records were applicable in utilization review and managed care, as well as in defense against ethics complaints and lawsuits alleging unethical conduct and professional negligence (Houston-Vega, Nuehring, & Daguio, 1997; Kagle, 1995b; Reamer, 2003). In addition, dramatic technological innovations--especially in the form of pervasive computerized records and the potential for problems concerning privacy and unauthorized access--fueled risk-management concerns. Together, these changes have resulted in a growing appreciation of how careful documentation and record keeping protect practitioners against allegations of ethical misconduct and professional negligence, guard clients' privacy, and facilitate the delivery of high-quality services.
In recent years, documentation-related standards have evolved to reflect these newer risk management functions. Most contemporary social workers, however, graduated before the current standards were developed and incorporated into social work curricula. In fact, the last major publication on documentation written specifically for social workers appeared in 1995--well before the emergence of several key current standards (Kagle, 1995b). Since then there have been noteworthy expansions of ethical standards on social work documentation (Reamer, 1998, 2003) and scholarly literature on the broader subject of documentation (Berner, 1998; Luepker & Norton, 2002). …