Social Work Documentation, 3rd Edition

About the Author
Acknowledgments
About This Book

Part I: Understanding Documentation

Chapter 1: Introduction to Social Work Documentation
Chapter 2: Documentation Today
Chapter 3: Laying the Foundation
Chapter 4: Special Issues in Documentation
Chapter 5: Language Selection Matters

PART II: Sections of a Case Record

Chapter 6: Information Summary Sheets
Chapter 7: Confidentiality, Release Forms, and Informed Consent Forms
Chapter 8: Assessments and Treatment Plans
Chapter 9: Documenting Client Progress
Chapter 10: Communication with and about Clients

PART III: Beyond the Basics

Chapter 11: Getting and Giving Feedback
Chapter 12: Supervision and Documentation
Chapter 13: The Future of Documentation

References
Index

Nancy L. Sidell, PhD, is a professor emeritus of social work at Mansfield University, Mansfield, Pennsylvania. She served as BSW program director, department chair, and dean of the faculty during her tenure at Mansfield University. Sidell has over 18 years of practice experience as a social worker in health, mental health, and nursing home settings. She is a professor of social work in Capella University’s DSW program and an exam development consultant with the Association of Social Work Boards. Additionally she is a coauthor (with Denise K. Smiley) of Professional Communication Skills in Social Work. She has also authored numerous journal articles. She lives in Wellsboro, Pennsylvania, and enjoys quilting, road biking, and hiking.

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The purpose of this book is to provide practical, hands-on experience to social workers wishing to improve their documentation skills. It stems from concerns about the wearing away of basic writing skills, hastened by a reduced emphasis on grammar and spelling at all levels of education and a devaluation of the writ­ten word. One example of this erosion is the appearance in formal kinds of writ­ing of shorthand abbreviations, previously acceptable only in informal electronic communications.

Social workers must document the services they provide, regardless of their educational level or the setting in which they are employed. Many are unprepared for this responsibility. Social work programs teach skills necessary for effective social work practice but often leave instruction about professional documentation to agency field instructors. Social workers should arrive at the workplace well prepared to document, but often they do not, and most agencies hiring new social workers must train them on the job.

Undergraduate and graduate students, as well as seasoned social workers, can benefit from instruction in the basics of social work documentation. This book is written with the goal of improving social workers’ writing skills and better pre­paring them for the written demands of their work. It can be useful as a reference tool in agency settings in which employees need assistance with documentation concepts.

This book reviews common formats and examples. It cannot, however, cover all of the documentation requirements that social workers may find during their careers or all of the settings in which social workers practice. The term “agency” is most commonly used to refer to the workplace throughout this book for effi­ciency purposes and in no way conveys the richness of the numerous settings in which social workers are employed. Neither does this book replace specific agency guidelines or jurisdictional rulings. Not all examples will be useful in every set­ting, given the wide variation in documentation requirements. Although this book cannot replace agency policy documents or supervisory guidance, it can serve as a learning tool.

The book is divided into three sections. The first five chapters give a general overview of documentation—its history, considerations that need to be addressed before documentation begins, special issues, and the importance of language. The second portion of the book reviews in turn the different components of a typical record. The last section focuses on ways in which documentation can be evaluated

and improved. Continuous skill improvement and supervisory issues are covered here, along with a look at future trends and directions. Over 130 exercises are found throughout the book, designed to build confidence about and knowledge of important aspects of documentation.

The exercises are designed to elicit written answers, which can be kept in a separate notebook or folder. Many of them are best completed with one or more peers who work through the exercises at the same time. Although the term “peer” is used throughout the exercises, a supervisor, fellow student, or colleague can fill this role. For example, a social worker may find that a supervisor’s feedback about the exercises is helpful to their professional growth. Alternatively, working with a peer who is also interested in improving documenting skills may be beneficial. Both social workers can work through the exercises and provide one another with helpful feedback. Specific and constructive feedback from a supervisor or peer can promote more polished and professional recording abilities. These skills will greatly enhance a social worker’s professionalism and ultimately result in better service to clients.