Rationale
Social work is a regulated profession with a high degree of legal and ethical accountability. Social workers adhere to a Code of Ethics, legislative mandates, and organizational policies. Federal and provincial legislation has also been created and amended to address issues pertaining to personal health 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.
The guidelines outlined in this document are informed by the Canadian Association of Social Workers Code of Ethics (2005), the Canadian Association of Social Workers Guidelines for Ethical Practice (2005), professional literature and guidelines and standards prepared by other provincial social work organizations (particularly the Newfoundland and Labrador College of Social Workers), as well as feedback from NSCSW members.
These guidelines are applicable to direct and indirect social work practice and can be adapted to specific practice areas. The guidelines do not replace organizational documentation policies, and social workers are encouraged to follow the laws, policies, and best practices of the organizations where they are employed, unless specifically in violation of social work values and the profession’s code of ethics. Social workers in private practice are responsible for developing their own policies in accordance with the best practice standards outlined in this document.
Definitions
The terms recording and documentation may be used interchangeably by social work practitioners, educators, and employers. Both terms are used in these guidelines.
The Social Work Dictionary (2014) defines recording as “the process of putting in writing and keeping on file relevant information about the client; the problem; the prognosis; the intervention plan; the progress of treatment; the social, economic, and health factors that contribute to the situation; and the procedures for termination or referral” (p. 358).
A social work record refers to a written or electronic document that contains client information, professional observations, clinical decisions, intervention strategies, and outcomes generated throughout the delivery of social work services.
Foundations
Documentation in social work practice is grounded in the values, ethics and principles of the social work profession.
Documentation is an integral part of social work practice. It is therefore important that social workers document all interventions in an ethical and competent manner.
The CASW Code of Ethics (2005) outlines the values and principles that guide professional social work practice. These values include:
- respect for the inherent dignity and worth of persons
- pursuit of social justice
- service to humanity
- integrity in professional practice
- confidentiality in professional practice
- competence in professional practice
Social work documentation guidelines pertain to all areas of social work practice including clinical practice, community development, management and supervision, research, education and policy development.
The purpose of social work documentation is to provide:
- A clear statement of social work assessment, intervention, and decision-making
- Professional accountability and transparency to the client and organization, and in keeping with relevant legislation
- Opportunity for critical thought and reflection on professional practice and service delivery
- Relevant information to facilitate service delivery, continuity of care and termination of services
- Information for the purposes of supervision
- Documentation for the purposes of research and program evaluation
- Information for risk management and quality assurance
- A record to facilitate inter-disciplinary communication and collaboration
Guidelines for Social Workers
Creating Records
Social workers maintain records of social work intervention(s).
Social workers have an ethical and legal responsibility to maintain social work records. Documentation of social work interventions with clients should be contained in one file. The records may be electronic, paper or both. Social workers should not maintain client information that is not relevant to the service delivery. Social work documentation should only include information that addresses the clients’ needs and meets legislative, ethical and organizational requirements.
It is the responsibility of the social worker to inform clients about what information is being documented, how it is being used, and who will have access to this information as part of the informed consent process. Social workers should also be aware of organizational policies and legislation respecting access to the professional record and rights of appeal. Social workers in private practice are responsible for developing these policies.
Informed consent is defined by the CASW Code of Ethics (2005) as a “voluntary agreement reached by a capable client based on information about foreseeable risks and benefits associated with the agreement (e.g., participation in counselling or agreement to disclose social work report to a third party)” (p. 10). Therefore, social workers document informed consent in the client record at the beginning of the social work relationship, and throughout the duration of the relationship as necessary.
Format
Social workers ensure records are in a format that facilitates monitoring and evaluation of the social work intervention(s).
Social work documentation is completed in a timely and chronological order to ensure accuracy, clarity and credibility of the information. Documentation should be completed following the intervention or as soon as reasonably possible afterwards. Social workers use professional judgment to determine if records need to be completed more expeditiously. The need to document a record more immediately may depend on the complexity of the case, degree of risk, impact on service delivery, and/or legislative requirements. Where organizational standards exist, social workers should be aware of and adhere to policies and timelines for documentation to be completed.
Social work records should contain all information that is clinically relevant and significant to the service delivery. At a minimum, records should include the following:
- Client’s name and contact information
- Presenting issue and description of professional service requested
- Client’s informed consent
- Copy of relevant documents (e.g., referrals, letters, court documents, etc.)
- Professional assessment (including risk assessment) as well as case conceptualization
- Treatment goals, interventions, and outcomes
- Progress notes
- Communication with other professionals and collateral contacts
- Clear statement of when and why the professional relationship is terminated
- Fee for service agreements (for those in private practice)
Records that are not clinically focused should contain at the minimum contact information for relevant partners and stakeholders, assessments, planning and implementation notes, records of meetings and communication with stakeholders, appropriate consent forms, pertinent research, and evaluations.
Financial documents may or may not be appropriate depending upon the context and the role of the social worker. Social workers should not collect documents that are unrelated to the services that are being provided.
The nature of the intervention or service delivery and organizational policies will shape the format and content of the social work record. When organizational policies pertaining to documentation practices are not developed or are vague and unclear, social workers advocate for documentation policies that are in keeping with the best interest of the client and standards for the profession. Clear documentation policies that include comprehensive assessments, as well as detailed descriptions of social work interventions and outcomes ensure ethical practice.
Social work records are to be dated the day they are written. Records that are completed on a different date from which the intervention occurred must clearly identify when the intervention or client contact occurred.
Social workers sign all records using their name and professional designation (e.g. social worker, Registered Social Worker, RSW, Social Worker Candidate, or SWC). Social workers should not sign records or reports authored by another social worker or professional. Social workers may co-sign records where appropriate.
Social work documentation should be free from jargon and emotive or derogatory language. Abbreviations should only be used after the term is explained the first time it is used in the record. This is important to avoid misunderstandings. Errors must not be erased or deleted; if corrections need to be made, they should be noted as such and dated and initialed by the social worker. To ensure the credibility of the note, social workers should also ensure that they use accurate spelling and grammar (Reamer, 2005).
Consultations with a supervisor, colleague, or consultant that is relevant to the service delivery should be documented in the client’s record. Clients should be informed that information may be shared with a supervisor or internal consultant as part of the social work service delivery when appropriate. Informed consent is necessary when client information is released to an outside consultant.
Reamer (2005) notes that staffing issues, disagreements with supervisors/managers, and opinions about the professional behavior of a colleague, should not be documented in the client file. Social workers may explore other organizational mediums to document these issues (e.g., administrative files, etc.). Similarly, documentation should not be used as the vehicle for which a social worker communicates with other members of the interdisciplinary team caring for the client. Furthermore, it is never appropriate for a social worker to document their own personal feelings about a client, nor their behavior.
Contents
Social work documentation shall include a clear assessment, intervention strategy and termination plan.
Documentation and assessment skills are interrelated. As noted by Leon & Pepe (2010), “how one interviews and assesses a client will determine how informative the client contact will be and consequently how much essential content one can include in the client documentation” (p. 365). Incomplete or inaccurate records can lead to inadequate services for the client.
Assessments are based upon facts that should be clearly documented in the client file. Only facts that are essential and relevant to the assessment or service delivery should be documented. The type of information considered relevant will depend on the context of practice and professional judgment of the social worker. All professional opinions need to be supported with facts, and professional observations must be distinguished from information provided directly by the client. Case conceptualization should be included within the client chart to help provide clarity regarding the services provided, but not necessarily in every case note.
On-going records and documentation should clearly identify the services to be provided, the client goals for intervention, and outcomes. The client is considered the primary source of information for the file. In circumstances where the client is not able to provide information to guide the intervention, social workers seek guidance from provincial statutes and organizational policies on who should be speaking on behalf of the client (e.g., next of kin, power of attorney, substitute decision-maker, etc.). Client information from referring organizations, professionals involved in the client’s care, and collateral contacts should also be included in social work documentation.
When social work relationships are terminated, the record should include a clear statement to indicate the end of the professional service. Social workers follow organizational policies and best practices guidelines regarding the retention of social work records after the professional relationship has ended.
Social workers in private practice are responsible for developing policies pertaining to the retention of social work records. Current best practices suggest that client records be kept for a minimum of seven to ten years from date of last entry, unless otherwise specified by legislation or organizational policy. If the client is under the age of 18 when the last entry is made, the client file should be kept for a minimum of 7 to 10 years from the date that the client turns or would turn eighteen. Social workers use professional judgment in deciding if records are needed to be maintained beyond this time frame. This may depend on the nature of the work and future need for the record.
Social workers are responsible for informing clients of the length of time in which records will be stored, security measures, and how clients can access them if needed during this time period.
Confidentiality
Social workers protect client confidentiality, and ensure that clients are aware of the limits of the confidentiality of social work documentation before initiating the social work relationship and throughout the relationship as needed.
The CASW Guidelines for Ethical Practice (2005) speaks to the importance of informed consent and privacy and confidentiality. It is important for social workers to reflect on these principles when preparing social work documentation.
Social workers take steps for protecting the confidentiality of a client’s written or electronic record. According to the CASW Code of Ethics (2005), it is important that social workers “take reasonable steps to ensure that clients’ records are stored in a secure location and that clients’ records are not available to others who are not authorized to have access” (p. 8).
When social workers provide services to more than one individual in a client system (e.g., families, couples and groups), it is important that all parties are informed of each person’s right to confidentiality and the confidentiality of information shared by others, and how records are being maintained. This information should be clearly documented in the client file. Clients being seen individually, in addition to the family, group or couple’s work, should have their own social work record.
As outlined in the CASW Guidelines for Ethical Practice (2005) “social workers ensure that clients have reasonable access to official social work records concerning them” (p. 10). Client access to personal information in clinical social work practice is also a right under applicable legislation (e.g., Personal Health information Act, 2010). The benefits of allowing clients to access their records may include:
- opportunity for clients to correct inaccuracies contained in the record,
- client can see where change is possible, and
- increase in trust of services being provided.
Social workers have a responsibility to ensure that clients are aware of organizational policies pertaining to client access to records. “If there are compelling professional, ethical or legal reasons for refusing access, social workers advise clients of their right to request a review of the decision through organizational or legal channels” (CASW Guidelines for Ethical Practice, 2005, p. 10). Social workers also take steps to protect the confidentiality of others when providing clients with access to their records (e.g., masking third party information, information about group members). When clients articulate complaints with regards to their records, social workers advise clients of appropriate complaints mechanisms.
The disclosure of client information and records to persons or organizations is permitted:
- With the informed consent of clients. This consent, written or verbal, should be documented in the client record.
- When disclosure is necessary to prevent serious, foreseeable, and imminent harm of the client or others. Social workers use their professional judgment to determine how much client information needs to be disclosed to prevent harm.
- When required by federal and provincial laws or regulations. The CASW Guidelines for Ethical Practice states that where the “consent of clients is not required, social workers attempt to notify clients that such access has been granted, if such notification does not involve a risk to others” (p. 9).
When disclosure of social work records is required by a court order or subpoena, social workers should be familiar with the nature of the request, seek consultation, take care not to release more information than is required, inform the client where appropriate, and strive to protect confidential client information from unreasonable public exposure. This may involve applying to the court for some client information to be withheld from the public record; however consultation with a supervisor or manager would be prudent in this situation.
Technology
Social workers are familiar with best practice guidelines pertaining to technology use and documentation.
Within the current context of technological advances, it is important that social workers take precautions to ensure and maintain the confidentiality of information transmitted to other parties through any form of electronic communication. Social workers should be aware of and inform clients of the limits to confidentiality that may apply to these forms of communication.
Nova Scotia social workers providing electronic social work services shall take all necessary measures to ensure compliance with relevant practice standards including those that govern their documentation. For information about standards specific to electronic social work practice and documentation, review the NSCSW Standards of Practice, particularly Standard 9: Technology & Storage of Files, and Standards for Technology and Social Work Practice published by the National College of Social Workers and College of Social Work Boards.
When team members or care providers communicate by e-mail or other electronic technologies, reasonable efforts must be made to ensure the protection of client privacy and confidentiality and risk management strategies must be put in place. Clients should also be informed about this method of team communication and documented in the client file as part of the informed consent process.
Learning
Social workers are familiar with best practice guidelines for completing social work documentation and engage in continuing professional education.
Reamer (2005) states “social workers must strive to continually strengthen their record-keeping practices to maintain the integrity of their programs” (p. 327). Social workers are responsible for being familiar with standards and best practice guidelines governing social work practice and documentation. As part of on-going professional development, social workers continue to assess their knowledge of social work documentation through self-reflection and consultation with peers, managers and/or supervisors and to engage in professional development opportunities to foster continued learning and competency.
Social workers engaged in supervision, including those involved in the provision of field instruction to students, ensure that social workers and students are familiar with the standards for social work documentation and best practice guidelines for documentation and writing, while seeking opportunities to enhance the competency of supervisees and students in social work documentation.
Community Responsibility
Documentation of community development processes, project planning, policy development, and research is grounded in the values, ethics, and philosophy of the profession; it reflects adherence to the Canadian Association of Social Workers (CASW) Code of Ethics (2005) and the CASW Guidelines for Ethical Practice (2005).
Social workers employed in community organizations and consulting work shall document their work with clients, families, groups, communities, employers and stakeholders in accordance with the standards set forth in these guidelines, and the CASW Code of Ethics.
Ethical Considerations
Documentation requires balancing workplace policies with social work ethics and clinical judgment. Here are some considerations about common concerns.
Navigating Dilemmas
Social work is a complex profession fraught with ethical and practice dilemmas. It is important that social workers document ethical decision-making processes when working through an ethical dilemma or issue with a client or client system in the social work record.
Examples of ethical issues that may be important to document in the client record include conflicts of interest, professional boundaries, dual and multiple relationships, and professional self-disclosure. One such concern may be if there is a difference between a social worker’s clinical judgment and the client’s wish regarding what should be documented.
Ripple Effects
Documentation of social work assessments and interventions can have significant ethical implications and legal consequences. Social workers must differentiate between formal documentation and informal written notes that provide more detailed information than is necessary but may be personally helpful to the clinician when trying to analyze the case or reflect upon their own responses as part of their case conceptualization.
The distinction between nice-to-know and need-to-know is a principle that can be helpful. How is social worker bias informing this decision? When there is doubt about whether something ought to be included in the client record, or the actions that are being undertaken, social workers are encouraged to engage in ethical consultation with the NSCSW.
Purpose
Section 9.2.6. of the NSCSW Standards of Practice states: “Social Workers shall ensure that all recorded information is either relevant to the solution of the client’s problems or is needed for agency administration, policy or legislation.”
While social workers should strive for objectivity, documentation can never be entirely neutral; there are always choices made about framing – about what is included and what is left out – and these are always ethical decisions. When dilemmas arise, social workers are encouraged to return to the fundamental purpose of documentation in terms of meeting ethical commitments to patients and clients and ensuring they receive the best possible care.
Vicarious Trauma & Secondary Stress
Social workers who are required to complete documentation regarding a work-related incident they witnessed, or experienced significant vicarious trauma from, should be granted the opportunity to receive support.
Due to the risk of re-traumatization as a result of completing their documentation requirements, and in order to ensure accuracy, social workers may wish to document with the help of a colleague or supervisor, who can assist in identifying which details should be recorded. In such a situation, both individuals should sign the documentation.
The NSCSW Standards of Practice (2022) set forth best practice standards for the supervision of social work practice. Standard 4.8.3. states: “Social Workers with management responsibilities shall provide for, or arrange for, appropriate debriefing and professional support for staff when they experience difficult or traumatic circumstances.”
Context
Social workers have a responsibility to complete documentation of their provision of professional services regardless of the context of their work, and to be familiar with the legal statutes that may apply to their practice.
Our professional scope of practice in Nova Scotia is defined by the Social Workers Act (amended 2015), in section 5A:
- For the purpose of this Act, the practice of social work means the provision of professional services to clients through the use of social work knowledge, theory, skills, judgement and values acquired through a program from an approved faculty of social work.
- The professional services to clients referred to in subsection (1) may include
- intervention through direct contact with clients, including assessment, case management, client-centered advocacy, education, consultation, counselling, crisis intervention and referral;
- community development founded on the principles of social justice that focus on mobilizing individuals to employ their skills to effect community change by community capacity building and community- based participation research; and
- direct or indirect provision of administrative, educational, policy or research services, including
- the development and promotion of social policies focused on improving social conditions and promoting social justice,
- the development, the provision and the administration of social-work services programs, and
- the supervision of individuals providing social work services; and
- such other activities as may be prescribed by the regulations.
References & resources
Legislation
Professional regulators & associations
- Alberta College of Social Workers (ACSW) (2013). Standards of practice. Calgary, AB.
- Australian Association of Social Workers (AASW) (2013). Practice standards. Canberra, ACT.
- British Columbia College of Social Workers (BCCSW) (2016). Code of ethics and standards of practice. Vancouver, BC.
- Canadian Association of Social Workers (CASW), (2005a). Code of ethics.
- Canadian Association of Social Workers (CASW), (2005b). Guidelines for ethical practice. Ottawa, ON.
- International Federation of Social Workers (IFSW). (2014). Global Definition of Social Work. Retrieved October 30, 2014 from website http://ifsw.org/policies/definition-of-social-work.
- National Association of Social Workers (2013). Standards for social work case management. Washington, DC.
- Newfoundland and Labrador Association of Social Workers (NLASW). (2014). Standards for social work recording. St. John’s, NL.
- Newfoundland and Labrador Association of Social Workers (NLASW). (2022). Social work recording (Explanatory document). St. John’s, NL.Nova Scotia College of Social Workers (NSCSW). (2016). Code of Ethics. Halifax,NS.Nova Scotia College of Social Workers (NSCSW). (2022). Standards of Practice. Halifax,NS.Ontario College of Social Workers and Social Services Workers (OCSWSSW). Code of ethics and standards of practice handbook (Second Edition). Toronto, ON.
Further reading
- Barker, R.L. (2014). The Social Work Dictionary (6th edition). Washington, DC: NASW Press.
- Blake, P. (2010). The broken record. Perspectives (Spring 2010). Toronto, ON: Ontario College of Social Workers.
- Bodek, H. (2010). Clinical documentation and recordkeeping. New York State Society for Clinical Social Work, Inc.
- Cumming, C; Fitzpatrick, E; McAuliffe, D; McKain, S; Martin C; and Tonge, A. (2007). Raising the Titanic: Rescuing social work documentation from the sea of ethical risk. Australian Social Work, 60(2), 239-257.
- Leon, A & Pepe, J. (2010). Utilizing a required documentation course to improve the recording skills of undergraduate social work students. Journal of Social Service Research, 36, 362- 376.
- Reamer, F. (2005). Documentation in social work: Evolving ethical and risk-management standards. Social Work, 50(4), 325-334.
- Reamer, F. (2011). When bad things happen to good social workers: The perils of ethics mistakes. Social Work Today. Retrieved April 23, 2013 from website http://www.socialworktoday.com/news/eoe_113011.shtml.
- Sidell, N. (2011). Social work documentation: A guide to strengthening your case recording. Washington, DC: NASW Press.
- Weisman, D., & Zornado, J. (2013). Professional writing for social work practice. New York, NY: Springer Publishing Company.
