Social Work Documentation

Introduction
Introduction
 Social work is a regulated
Introduction profession with a high degree of legal
and ethical accountability.

Social workers adhere to a Code of

Ethics, legislative mandates, and
organizational policies.

National legislation has also been

created and amended to address issues
pertaining to personal information and
privacy.

It is therefore imperative that social

workers are familiar with best practice
standards and legislative requirements
impacting on all aspects of practice
including documentation.
Introduction Documentation is an
essential component of good
social work practice. Yet, when
competing demands arise,
documentation receives a lower
priority.

This module will explore

considerations for effectively
integrating documentation into
social work practice ensuring
the highest quality of
professional intervention.
Intended Learning
Outcome
 ● Discuss the history and
Intended Learning importance of social
Outcome work documentation;
● Acknowledge the
content of good social
work documentation
and avoid barriers to
effective
documentation; and
● Describe the importance
of social work
documentation in the
profession.
Definition of
DOCUMENTATION
Definition of
“You might believe that good
DOCUMENTATION writing comes naturally for
some people, but even for the
experienced writer, it is hard
work” (Szuchman & Thomlison,
2008, p. xi).

Social work documentation, like

any good writing, is
A SKILL THAT IS BUILT.
Definition of The Oxford English Dictionary
Online defines documentation
DOCUMENTATION as “the accumulation,
classification, and
dissemination of information”
(“Documentation,” 2013).

In social work, its meaning is

even more specific. The term is
well known to students and
practitioners alike, despite the
fact that it does not appear in
the sixth edition of the Social
Work Dictionary (Barker, 2014).
Definition of It is a communication tool with
which social workers record
DOCUMENTATION their work; the means by which
cases are managed; and the
manner in which services are
evaluated, assessed, and often
reimbursed.

It is a required professional
social work function, a
permanent record of client
service provision.
Definition of Social workers often have a
negative response to
DOCUMENTATION documentation—it is the bane
of many professionals’
existence.

To many social workers, it

means spending time away
from their true passion of
working with clients, responding
to unnecessary bureaucratic
demands, and tending to
tedious and boring details.
Definition of Overworked social workers do
not appreciate the requirement
DOCUMENTATION for case recording and often
delay the task.

The phrase “if it’s not

documented, it’s not done” is
commonly used to encourage
better documentation habits,
but the particulars of how to do
so are less well noted.
History of
Documentation
History of The lack of appreciation for
case recording is nothing new.
Documentation
Colcord and Mann (1930) wrote
that “the charity organization
group learned early to keep
records, and some of their
number, as time went on,
became very much dissatisfied
with the clumsy way of doing
things revealed by these
records” (p. 585).
History of From the beginning of organized social
work, efforts were made to record
Documentation information about cases. Often, these
notes were kept in public files in local
offices and had minimal content
(Strode, 1940).

Timms (1972, p. 9) noted that early

recording of service delivery took the
form of a registry in which poor-relief
workers entered the name of the client;
the amount of cash assistance provided;
the client’s residence; and a few
remarks such as “destitute,” “very
aged,” or “large family.” These cursory
notes were often the only record of
service delivery.
History of The next phase of documentation,
beginning in the last half of the 19th
Documentation century, was characterized by more
detail and verification of key facts
(Timms, 1972).

Guidelines presented at the first

national Conference of Boards of
Public Charities in 1874 illustrate
this type of documentation.

They advised including the

following items in the record:
History of ● Kinds of mental and moral
perversion;
Documentation ● Descriptions of morbid and
debasing conditions of the mind;
● Points at which neglect of social
and moral duties began;
● Information regarding the totally
idiotic or weak-minded in three
generations, living and dead;
● Total inebriates in three
generations, living and dead; and
● Capacity for self-support without
the direction and control of a
superior authority or constant
advice and supervision.
(Conference of Boards of Public
Charities, 1874, pp. 88–89)
History of Documentation content has changed since
1874, but it is still a work in progress for the

Documentation profession.

In 1922, Mary Richmond wrote that “the habit

of full recording is not yet well established” (p.
30).

Depending on the location in which services

were provided, the habit seemed to vary
widely. In the same year that Richmond
wrote these words, Josephine Brown, a
pioneer in rural social work, advised against
keeping notes on services delivered: “The
taking of notes is even less advisable in the
country than in the city. . . . Unless some
obvious reason for using paper and pencil
exists—such as securing information for the
court—notes are out of the question” (Brown,
1922, p. 188).
History of Disagreeing with Brown five years later
was Harold J. Mathews.
Documentation One of the greatest sins of the rural
case worker, which she is more guilty of
than the city worker, is that she does not
keep as good records. Too many times
we find them with only copies of letters
and a few ragged notes, if anything at
all. This is not fair to the profession and
the development of the work in rural
sections, to say nothing of being unfair
to the client and the next case worker
who comes along. It is bad business to
say the least. (Mathews, 1927/1980, p.
172)
History of In 1932, Brown wrote this of rural case
records: “If any information about a family

Documentation receiving relief is on record anywhere, it may

be in the pocket notebook of a county
supervisor” (p. 17). Clearly, inconsistency and
loose practices seemed to be prevalent and
accepted.

Case notes were a challenge for more than

just rural social workers. When the Federal
Emergency Relief Administration was
established in 1933, there was an immediate
need to obtain information about relief given
to the unemployed and their families across
the United States. A research division tasked
with developing a standardized means of
reporting relief statistics was created for the
first time in the country’s history.
History of There were in existence few
satisfactory state systems for
Documentation reporting the numbers of relief
recipients and the amounts of
expenditures. As a result, a vague
uncertainty prevailed concerning the
size of the relief problem. . . . Little
was known about the characteristics
or composition of the relief
population. (Brown, 1940, p. 194).
History of In 1934, poor-relief workers still kept
little or no permanent record of their
Documentation services:

Checkbook stubs, loose sheets of

paper, duplicate order blanks, and
pocket notebooks are frequently the
only evidence of such uses to which
public funds have been put. In
several instances even such informal
memoranda are lacking. Some poor
directors have destroyed their
records upon going out of office.
(Pennsylvania Department of Public
Welfare, 1934, p. 87)
History of Records were often inadequate and
inaccurate.
Documentation
Prior to 1937 and the passage of the
Public Assistance Law, 967 people
were responsible for the
administration of poor relief in
Pennsylvania’s 425 established
districts. The organization of relief in
Pennsylvania was likely not unique.
Administrators there maintained very
few records, which were described as
usually fragmentary and
unsatisfactory.
History of They supplied but little information
regarding relief expenditures or the
Documentation circumstances of the recipients which
justified helping them with public
funds. The records often consisted of
no more than the lists of names of
relief recipients which were printed in
annual reports of the county
government or in the newspapers,
supplemented by the financial reports
of the county treasurers which gave
unitemized amounts of grocers’ bills
and the accounts of other tradesmen
who furnished goods to the poor.
(Brown, 1940, pp. 15–16)
History of In the late 1930s, the trend in social
work documentation turned from scant
Documentation notes to process recordings (Timms,
1972). Although never practiced on a
day-to-day basis, process recordings
signified an attempt to document
everything. From there, the pendulum
swung back to a compromise between
keeping a simple register and detailing
everything: differential recording, which
involved selectively choosing what was
considered the most important content
to record. A narrative summary account
of services provided, based on the
unique nature of the case, gradually
emerged.
History of By the mid-1950s, the selective and
analytic diagnostic record was widely
Documentation used (Kagle, 1984b). This type of
record existed primarily to show the
worker’s supervisor how the case was
being approached. Changes in the
1960s and 1970s included an
increased demand for accountability,
early computer technology, and new
complexities in service funding, all of
which had an impact on the
record-keeping practices of social
workers.
History of A survey conducted in 1979 and 1980 revealed
that educational supervision was no longer

Documentation the primary function of social work records.

They were being used increasingly for
purposes such as ensuring continuity of
services, evaluating effectiveness of service
delivery, and enabling professionals involved
in the same case to communicate with one
another (Kagle, 1984b). Audiences included
other service providers, clients, and funding
sources.

During this period, the conviction emerged

that no single approach to documentation
met each need in every case (Timms, 1972).
This new approach stressed flexibility based
on the client’s situation and agency
requirements.
History of Although no one recording formula will
be effective in all cases, a systematic
Documentation approach to documentation can be
helpful, particularly for inexperienced
workers and for seasoned professionals
working with a new population.

Despite a great deal of variety in

today’s documentation styles, one point
remains clear:

Documentation is essential to
the effectiveness of social
workers and the well-being of
their clients.
History of Efforts
to Teach
Documentation
History of Efforts Three books were written about case
documentation between 1920 and 1936
to Teach (Timms, 1972)—more titles than at any
other time.
Documentation
Sheffield’s (1920) The Social Case
History: Its Construction and
Content identified three purposes for
documentation: improving client
treatment, advancing and improving
society, and enhancing the worker’s
critical thinking skills.

Bristol’s Handbook on Social Case

Recording and Hamilton’s Social Case
Recording were published in 1936.
History of Efforts Hamilton argued that standardization
of record keeping was impossible:
to Teach “There is no such thing as a model
record, no routines which will make the
Documentation case inevitably clear, accessible, and
understandable. Records should be
written to suit the case, not the case
geared to a theoretical pattern”
(Hamilton, 1936, p. 2). Hamilton
predicted that practice and
documentation skills would develop
simultaneously, a notion that is also
prevalent today.
History of Efforts More recent books were written by Timms
in 1972 (Recording in Social Work) and by
to Teach Wilson in 1980 (Recording Guidelines for
Social Workers). Both offered practical
Documentation guidelines on elements of recording.

Kagle’s Social Work Records followed in

1984; it is currently in its third edition
(Kagle & Kopels, 2008).

Although many social work practice texts

include introductory material on
documentation skills and methods (for
example, Kirst-Ashman & Hull, 2011;
Sheafor & Horejsi, 2012), practical
recording guidelines are not included.
History of Efforts Documentation should matter to
every practicing social worker and
to Teach every student considering entry into
the profession.
Documentation
It is a vital professional responsibility
in which ongoing training is needed.

This module will provide specific

training on documentation to help
social workers prepare for and
manage their record-keeping
responsibilities.
The Importance &
Purpose of
Documentation
The Importance & Creating effective documentation
can seem like a monumental task,
Purpose of and companies often don’t know
where to get started, which is why
Documentation this article was created to walk
you through it.

Here is everything you need to

know on creating clear and concise
documentation.
Why
Documentation is
Important?
Why You’re probably wondering exactly
why you need to care about
Documentation is documentation in the first place.
Important? Most organization will pride
themselves on the fact that their
staff know how to do their jobs, and
seem put off by the tedious process
of jotting everything down.
Why While they may be right in saying that
their team knows how to go about
Documentation is their tasks, they shouldn’t use that as
an excuse to skip documenting.
Important?
As we said earlier, effective
documentation is the building block
of team management and plenty of
other tasks such as outsourcing, and
plays a major role in streamlining an
organization’s business practices.
Here’s why:
Building Company If one day in the future you were to
sell your company, one of the things
Value that gives it value is the processes
and work attached to it.

Documentation can help increase

future share price, by making it easier
to understand the processes of a
company and determine its value.
Getting the Most Reviewing documentation can shed
light on the processes a team uses,
Out of the Team and potentially help them see places
where those processes could be
streamlined.
Collaboration Documentation can make
collaborating with people much
easier, and cut down on meetings
during the week.

Particularly if you are using a tool

such as Google Docs for your
documents, you can easily document
a process, share it with your team,
and brainstorm ideas to improve it, all
without wasting time
Reduced Training In addition to helping the existing
staff optimize their processes, making
Time sure everything the team does is
clearly documented can also help
train new hires quickly.

Documentation can help get new

hires up to speed without costing the
existing staff valuable time and
effort.
A Guide for If and when an organization decide
to outsource parts of their business,
Outsourcing Tasks documentation becomes invaluable in
making sure all of their outsourced
employees know what they doing and
what is expected of them. Depending
on what tasks they outsource and
where to, having clear and simple
instructions for them to follow.