Discussion 6
Discussion
Documentation is very important in social work practice. As professional social workers, we document everything that happens with a client. We utilize a number of different documentation tools, including:
- Contact notes – form where you describe your contact with the client (via phone, face to face, etc.)
- Collateral contact notes – form where you describe the contact with someone other than the client (teachers, family member, probation officer, etc.)
- Assessments – initial form used to gather the client’s history
- Treatment plans – form where you describe, in detail, the client’s goals (sometimes called goal plans, service plans, or intervention plans)
- Release of Information – form utilized to get permission from the client to share their personal, confidential information with others
When writing out documentation, it is often helpful to follow the S.O.A.P. format. When following S.O.A.P a worker should be SUBJECTIVE and OBJECTIVE in their documentation. The worker should also provide an ASSESSMENT of the client’s functioning and reaction to the interaction with the worker. Finally, the worker should include a PLAN for moving forward.
Each of the different forms of documentation are utilized so we can provide detailed information about our work with our client. When social workers document client’s information we strive to make sure that we utilize specific techniques in order to avoid a number of common errors. See the following table for what to include and what to avoid.
Techniques to Include
- Person first language
- 3rd person language
- Client’s strengths (Strengths Based Approach)
- Quotation marks when you note what the client said
- The date that the encounter took place and your signature
- Black ink if handwritten or typed
- Non-biased language
- Grammatically correct English
- Clear, specific, and concise sentences
- Differentiate between what is a fact and what is your professional impressions. Be sure to include language that introduces your professional impressions
What to Avoid
- I, We, Our or You statements
- Pencil, white out, or blue ink
- Language that your clients do not understand
- Professional impressions stated as if they are facts
- Biased language (including hostile, offensive, and judgmental language)
- Use of Stereotypes (making assumptions about clients)
The following examples will help you better understand what to include and what to avoid.
- Incorrect Way to Document: The client had unprotected sex with her father and is now pregnant with his child.
Correct Way to Document: Bianca, a 14-year-old, African American female was repeatedly sexually assaulted by her father. Due to these incidents of sexual assault by her father, Bianca is now pregnant with her second child.
Correct Technique Used: Non-biased language; Clear, specific, and concise sentences - Incorrect Way to Document: The addict says she wants to change, but she is not telling the truth.
Correct Way to Document: Amy, a person who is currently using illegal substances, stated in our last session that she wanted to stop using heroin. This social worker noticed that this statement contradicts her reported behavior of using heroin last night.
Correct Technique Used: Person first language; Stating professional impressions; Non-biased language; 3rd person language (when referring to social worker) - Incorrect Way to Document: The client is whining about her current life situation, because she recently learned she is an HIV positive person.
Correct Way to Document: The client expressed sadness and confusion about her recent HIV positive diagnosis. She stated that she “does not know how to cope” and that she “doesn’t know how to tell her family”.
Correct Technique Used: Clear, specific, and concise; Quotation marks to identity the client’s own words; Non-judgmental language - Incorrect Way to Document: The client is from Baltimore, MD and so he is likely involved in a gang and has a history of violent behaviors.
Correct Way to Document: The client is from Baltimore, MD.
Correct Technique Used: Clear, specific, and concise; Non-judgmental language; Avoidance of stereotyping - Incorrect Way to Document: The clients showed up for their appointment and they were talking loud and ghetto.
Correct Way to Document: The clients presented for their appointment with this worker.
Correct Technique Used: Clear, specific, and concise; Non-judgmental language
Look at following examples. For each of the incorrect documentation statements you will need to write out the correct way to document the client interaction. You will also need to identify the specific techniques that were utilized to correct the documentation statement.
Incorrect Way to Document: The client seemed to have a hard time expressing himself. I think he might be slow or have some type of learning handicap.
Correct Way to Document
Technique Used
Incorrect Way to Document: This mom came in for her session and she had a lot of kids with her and they all had different dads. She asked for help with food and housing but it doesn’t seem like she’s serious about really helping herself.
Correct Way to Document
Technique Used
Incorrect Way to Document: I think the client has low self-esteem and just needs help finding a girlfriend and learning how to be a man.
Correct Way to Document
Technique Used
