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The Writer’s Handbook: A Guide for Social
Workers
Chapter 2
Documentation and Forms
By Marsheila Harris, MSW, Indiana University Northwest
©2014 The Writer’s Toolkit, Inc. All Rights Reserved.
If it is not written, it did not happen.
In social work, this saying speaks to the urgency of maintaining strong documentation in the field.
Social workers must submit well-written forms and documents for the agency and for external service providers and collaborators.
Reports are routinely sent to the courts, medical community, criminal justice departments, and other agencies as part of a case file that serves as an official document.
The reports are used to assist in decision making for the client’s well-being and to provide services or resources.
National Association of Social Workers (NASW)
The NASW Code of Ethics are at the core of
social work, providing guidance to social
workers about commitment to clients,
confidentiality, and professionalism.
The NASW Code of Ethics articulates basic
values, ethical principles, and ethical
standards to guide social workers’ conduct.
NASW Code of Ethics
The National Association of Social Workers Code of
Ethics also addresses the need for accurate and
professional documentation (2008).
To view the entire code, go to the NASW website:
http://www.socialworkers.org/pubs/code/code.asp
Let’s take a look at some parts of the code that relate to
documentation.
1.07. Privacy and Confidentiality
a. Social workers should respect clients’ right to
privacy . . . and not solicit private information unless
it is essential to providing services or conducting
social work evaluation or research. Once private
information is shared, standards of confidentiality
apply.
b. Social workers may disclose confidential information
when appropriate with valid consent from a client or
a person legally authorized to consent on behalf of a
client.
c. Social workers should protect the confidentiality of
all information obtained in the course of professional
service, except for compelling professional reasons .
. . only information that is directly relevant to the
purpose for which the disclosure is made should be
revealed.
d. Social workers should inform clients, to the extent
possible, about the disclosure of confidential
information and the potential consequences . . . .
3.04 Client Records
a. Social workers should take reasonable steps to
ensure that documentation in records is
accurate and reflects the services provided.
b. Social workers should include sufficient and
timely documentation in records to facilitate the
delivery of services and to ensure continuity of
services provided to clients in the future.
c. Social workers’ documentation should protect
clients’ privacy to the extent that is possible and
appropriate and should include only information
that is directly relevant to the delivery of services.
d. Social workers should store records following the
termination of services to ensure reasonable
future access. Records should be maintained for
the number of years required by state statutes or
relevant contracts.
1.12 Derogatory Language
Social workers should not use derogatory
language . . . . Social workers should use accurate
and respectful language in all communications to
and about clients.
NASW Press Guidelines for Describing People (2011)
The purposes of the guidelines are to help authorsportray people as accurately and vividly as
possibleeliminate bias from their writingincorporate the richness of cultural diversityuse language that is accessible and inviting to the
reader.
NASW Press Guidelines
Seek and use the preference of the people you write about.Ask people how they prefer to be described
Be as specific as possible.
Whenever possible, use specific racial or ethnic identities instead of collecting different groups under a general heading, such as Hispanics.
Cite actual ages rather than using a term such as older people or senior citizens.
Describe people in the positive.
Describe people for what they are rather than what they are not; do not use terms such as nonwhite or nonparticipant.
Help the reader see that you are writing about
people, not subjects or objects.
Use the terms sample or subject for statistics and describe participants as respondents, participants, workers, and so forth.
Avoid using terms that label people.
When adjectives that describe a person's
condition or status are used as nouns, they
become labels that often connote a
derogatory intent.
People who have lived a long time become the
elderly or the aged; if you cannot use specific
ages or age ranges, use terms such as elders or
older people.
Using “the” in front of a noun is a sign that you may be using a label.
Labels Revised
the disabled people with disabilities
the handicapped people with disabilities
the blind people who are blind
the lower class people who are poor
the upper class people with high incomes
the disadvantaged people who have disadvantages
Use gender-neutral language.
Outdated Current
policemen police officers
housewife homemaker
mailman mail carrier
fireman firefighter
chairman chairperson
salesman sales representative
Can you think of more examples?
Use plural nouns to avoid singular, gender-specific pronouns.
Gender biased:
A social worker should consider his mission . . .
A social worker should consider her mission . . .
Incorrect:
A social worker should consider their mission . . .
Revised:
Social workers should consider their mission . . .
More Examples
Poor Usage Revised
schizophrenics people diagnosed with schizophrenia
challenged people with challenges
wheelchair-bound uses a wheelchair
AIDS victims people with AIDS
high-risk groups high-risk behavior
minority racial and ethnic groups
tribes people or nations
blacks black people
nonwhites specific population
Hispanic Cuban Americans, Mexican Americans,
Puerto Ricans
You will find the NASW Press Guidelines for
Describing People in their entirety at the following:
https://www.naswpress.org/authors/guidelines/08c-
tools.html
The guidelines are also posted at your text’s website:
www.thewriterstoolkit.com
Click on the Social Work Resources tab.
Documentation in the Field
Court Summaries
Social Histories
Client Intake Forms
Treatment Plans
Case Notes
Case Notes
Case notes are professional records of the case worker’s interaction with the client, providing a documentation of what was discussed, agreed upon, or unresolved.
Case notes serve as proof of the case worker’s contact and whether or not the client is compliant with services.
Case notes have moved from being handwritten to being completed using a computerized template.
Case Notes
Client Name:ID No. Date of BirthCase Worker Name:
Date of Interaction:
Case Notes:
Questions
Throughout your process:Separate composing from editing