Social work documentation Examples

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Brenda is a clinical social worker affiliated with a group practice. For years, she has specialized in the treatment of depression, anxiety, interpersonal conflict, and other mental health issues.

One of Brenda’s clients, Mary, has struggled for years with depression, tension in her primary relationships, and low self-esteem. Brenda has provided Mary with weekly counseling sessions for nearly two years.

In recent weeks, Mary has called Brenda at her office more frequently, insisting that Brenda speak with her on the telephone and requesting additional office appointments. When Brenda tried to set limits and restrict their contact, Mary accused Brenda of not caring about her. On several occasions, Mary threatened Brenda, telling her that she would have “to do something drastic” if Brenda did not make time for her. During the next several weeks, Mary’s demands escalated, reaching a point where Brenda began to conclude that she could no longer work effectively with Mary. Brenda brought up these issues in her biweekly peer supervision group and began to formulate a plan to terminate her professional relationship with Mary and refer her to another provider.

Brenda met with Mary and spoke with her about her concerns. Mary responded angrily and walked out of the office. Mary then started to leave desperate and occasionally hostile telephone messages on Brenda’s voicemail system and, several weeks later, attempted to commit suicide by taking an overdose of medication. Mary survived the suicide attempt and subsequently filed a formal ethics complaint against Brenda with the state board. Mary alleged in her complaint that Brenda was unethical in the way that she abruptly terminated services. Mary claimed that Brenda’s “abandonment” of her directly caused her despair and subsequent suicide attempt.

At the formal ethics hearing, which was conducted before a panel of Brenda’s professional peers, Mary reiterated the allegations contained in her written complaint. In response, Brenda testified that she handled the challenging clinical situation professionally and ethically. She talked in the hearing about how she discussed the issues with colleagues in her peer consultation group, telephoned a psychiatrist who specializes in the treatment of individuals who have been diagnosed with borderline personality disorder, and carefully planned for the termination of services. In her rebuttal, Mary was adamant that Brenda had not talked with her at length about the reasons for terminating services or Mary’s options for treatment elsewhere in the community.

The chair of the committee asked Brenda to produce copies of her clinical notes (the release of which Mary had authorized); the committee was eager to see pertinent details concerning Brenda’s consultation with colleagues and discussion with Mary related to termination of services and referral of Mary to other professionals in the community. The committee was surprised to hear Brenda’s terse response: “I’ve been in practice for 28 years and I’ve never kept detailed notes. I just wasn’t trained that way. Are you saying my word about what happened isn’t good enough?”

As in this case example, social workers sometimes find themselves in situations where they must be able to provide evidence of their conduct and actions during some time in the past—whether the immediate or distant past. This may occur in the context of litigation (for example, when a former client files a malpractice claim alleging some kind of professional negligence) or adjudication of an ethics complaint filed with a state licensing board or the National Association of Social Workers. Although most social workers understand the importance of careful and thoughtful documentation, some do not.

The bottom line is that careful and diligent documentation enhances the quality of services provided to clients and, ultimately, can protect practitioners. As the NASW Code of Ethics states, “(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 to ensure continuity of services provided to clients in the future” (standard 3.04). Comprehensive records are necessary to assess clients’ circumstances; plan and deliver services; facilitate supervision; provide proper accountability to clients, other service providers, funding agencies, insurers, utilization review staff, and the courts; evaluate services provided; and ensure continuity in the delivery of future services. Skilled documentation also helps to ensure quality care if a client’s primary social worker becomes unavailable because of illness, disability, vacation, or employment termination. Also, thorough documentation can help protect social workers who are named in lawsuits or ethics complaints.

In typical clinical settings, documentation should ordinarily include (Reamer, 2001)

• a complete social history, assessment, and treatment plan that states the client’s problems, reason(s) for requesting services, objectives and relevant timetable, intervention strategy, planned number and duration of contacts, methods for assessment and evaluation of progress, termination plan, and reasons for termination;

• informed consent procedures and signed consent forms for release of information and treatment;

• notes on all contacts made with third parties (such as family members, acquaintances, and other professionals), whether in person or by telephone, including a brief description of the contacts and any important events surrounding them;

• notes on any consultation with other professionals, including the date the client was referred to another professional for service;

• a brief description of the social worker’s reasoning for all decisions made and interventions provided during the course of services;

• information summarizing any critical incidents (for example, suicide attempts, threats made by the client toward third parties, child abuse, family crises) and the social worker’s response;

• any instructions, recommendations, and advice provided to the client, including referral to and suggestions to seek consultation from specialists (including physicians);

• a description of all contacts with clients, including the type of contact (for example, in person or via telephone or in individual, family, couples, or group counseling), and dates and times of the contacts;

• notation of failed or canceled appointments;

• summaries of previous or current psychological, psychiatric, or medical evaluations relevant to the social worker’s intervention;

• information about fees, charges, and payment;

• reasons for termination and final assessment; and

• copies of all relevant documents, such as signed consent forms, correspondence, fee agreements, and court documents.

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