Transcript Strength and Empowerment Through Documentation.

Strength and Empowerment
Through Documentation
Karlynn BrintzenhofeSzoc, DSW
National Catholic School of Social Service
Catholic University of America
Washington, DC
This presentation is the intellectual property of the author and may be used only with written
permission and appropriate credit.
DO YOU WORRY ABOUT….
..your written documentation showing your
treatment is consistent with professional
standards of practice?
 ..your written documentation communicates
the work you are doing?
 ..your written documentation assists other
professionals in following a case?
 ..your written documentation provides
enough guidance for another professional to
pick up where you left off?
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DOES YOUR CURRENT
DOCUMENTATION SYSTEM:
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…utilize narrative documentation?
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…comply with professional standards?
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…follow the policy and procedures that
compliment the practice setting which
supports delivery of service?
…record effectively, educate and
communicate with others the delivery of
social work/mental health services?
DOES YOUR CURRENT
DOCUMENTATION SYSTEM:
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…utilize a Peer Review System to enhance
social work performance and service delivery?
…support cost effective service delivery?
…if a computerized record, effectively provide
information to support professional standards
of practice?
PURPOSE OF DOCUMENTATION
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To assist in planning client care and in
evaluating the client’s condition and ongoing treatment.
To document the course of the client’s
evaluation, treatment and change in
condition.
To document communication between the
responsible practitioner and other
professionals contributing to the client’s
care.
PURPOSE OF DOCUMENTATION
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To assist in protecting the legal interest of
the client, the agency, and responsible
practitioners.
To provide data for use in continuing
education and research.
To educate others on the services
provided, the range of skills utilized,and
the impact social work services have on
patients, families, the team, the institution
and society.
Content of Good Social Work
Documentation
CONTENT OF NOTE
 Full name of patient/client and
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identification number on each page.
Complete date and time of interview.
Complete date recording was written.
Purpose of interview.
Description of problem areas identified by
social worker/mental health provider
and/or client.
Plan for future meetings.
Signature of interviewer.
STICK WITH THE FACTS
Factual
Accurate
Complete
Timely
System
Bergerson (1988).
STICK WITH THE FACTS
Factual
Describe objectively what you see, hear,
smell and physical/behavioral changes.
Accurate
Document sequence of all events as they
occurred and only for your practice. Be sure
to include the who, what, where, when, the
time, place, and persons involved.
STICK WITH THE FACTS
Complete
If you didn’t document it, it didn’t happen.
Document all contacts, telephone,
patient/family contacts and consultation.
Timely
Your notes should be written to meet the
standards of your documentation policy and
when your memory is clear on the events.
STICK WITH THE FACTS
System
That effectively records, educates and
communicates to the health care team the
delivery of social work/mental health client
care services.
It should be consistent across all disciplines.
Principles In Recording
Client/Patient Information
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Know the difference between privacy,
confidentiality and privileged
communications.
 Know the potential audience, verify
identity, and the purpose information
is requested.
Principles In Recording
Client/Patient Information

Recorded information should be factual,
accurate, objective and necessary.
 Recorded information should be clear,
concise, and specific.
 Services provided should be clearly identified.
 Treatment provided based on professional
assessment that can supported.
Principles In Recording
Client/Patient Information

Know federal and state laws regarding
confidentiality.
 Know the Code of Ethics and how it applies
to confidentiality.
 Know how to protect confidentiality when
using technological means to transmit
information.
Guidelines To Promote And Protect
Confidentiality
 Know levels of confidentiality
 Explore how confidentiality is protected by
your agency/institution and by managed care
companies.
 Educate professionals, providers, and
students about confidentiality with advanced
technology.
Levels of Confidentiality
Absolute
The social worker/mental health provider does
not divulge confidential material under any
circumstance.
Relative
Confidentiality can be breached under certain
circumstances.
Clients Records and the Law
Remember social work and mental
health records are legal documents.
Be aware that e-mail communications
can be pulled for legal review.
E-mail can also be reviewed by your
employer.
Keeping Computer Records
Private
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Preventing unauthorized access to
confidential information.
 Password protection
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Never share your password
Do not use the same password for everything
Regularly change your password
Biggest threat comes from within an
organization not from outside
Keeping Computer Records
Private
 Computers crash and burn …
 So regular backups are very important
 All computerized documentation needs to
have a backup in a secure location.
Keeping Electronic
Transmission Confidential
 Understand the limits of e-mail
 Have informed consent from clients before
providing information to them or anyone else
via e-mail
 Know who else may be on the other end of the
e-mail
Other types of notes
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Process journals
Process recording
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Used by social worker/mental health professional
to deal with their own feelings, thoughts,
reactions. If about therapist not likely to be
subpoenaed.
If it includes client focus can be subpoenaed.
Any notes you take on a client can be
subpoenaed.