Professional Documentation in SSW

Question 1

What are the standards of Case Recordings?

Answer 1

Written reports; could also be typed on the computer

“Based on notes; the better your notes are, the better your report”

Question 2

What are the standards of Telephone contacts?

Answer 2

“Less is best”

Invite callers in; it is always best to meet face-to-face

Question 3

What are the standards of conference notes?

Answer 3

Minute taking

Question 4

What is ‘Minute taking’?

Answer 4

Students are often asked to take minutes

Must record:
• Attendance: first and last name
• Regrets
• Absence
• Approval of previous minutes
• Other business

Question 5

What is written on the first of three pages of ‘Progress Notes’?

Answer 5

1. Name and Agency
2. Date/Time
3. Observations; did they pay attention when you spoke to them, body language, who was with you in the meeting?
4. Recent/Relevant/Significant content of the case
5. Content of the 50 minute session

Question 6

What is written in the second page of ‘Progress Notes’?

Answer 6

1. Date and time
2. Assessment; is this the same or different from last session (if there is more than one session)
3. Action Plan; plan to do with the client, involves goal setting, red flag items
4. Homework Assignments

Question 7

What is written on the third page of ‘Progress Notes’?

Answer 7

1. Date and time
2. Follow up sessions; pieces that are a part of the plan; referrals
3. Next meeting; along with SSW signature

Question 8

What are ‘Red Flag’ items?

Answer 8

Items of concern; always at least two. Includes violence and suicide; must write ‘yes’ and add comments

Question 9

What type of information should a SSW note?

Answer 9

• Contact date
• Client’s presenting concern or problem
• Client’s family and social supports
• Client’s health
• Employment
• Client’s cultural background
• Activities
• Changes since last meeting
• Time spent
• Persons in Attendance
• Themes
• Interventions
• Plan/Homework
• Signature

Question 10

What are ‘Client records’?

Answer 10

Describe the client’s current situation/problem and the intervention provided

Question 11

What are the requirements of ‘Client Records’/best practices of note taking?

Answer 11

• Chronological order
• Unbiased and objective/ NEVER record impressions as face/Qualify statements with facts
• Refer to self as “this worker” or “this writer” versus “I”
• Legible black ink
• Don’t gloss over negatives, but also don’t describe only positives
• Spell out if you use acronyms and abbreviations
• Date and time of meeting
• Can include quotes
• ACCURACY; corrections - line through with new addition; sign and date

Question 12

Note taking structures: What is ‘DAP’?

Answer 12

Data, Assessment, Plan

Question 13

Note taking structures: What is ‘PIG’?

Answer 13

Problem, Intervention, Goal

Question 14

Note taking structures: What is ‘SOAP ‘?

Answer 14

Subjective, Objective, Assessment, Plan

Question 15

Note taking structures: What is ‘SOAPIER’?

Answer 15

Subjective data, Objective data, Assessment/Analysis, the Plan, Interventions, Evaluation, Revision

Question 16

In ‘SOAP’, what is subjective data?

Answer 16

Professional impressions/how client feels

Example: “it appears that…” (Not personal views or feelings)

Question 17

In ‘SOAP’, what is objective data?

Answer 17

Facts and observations. Supported by quotations from client, family, Doctor

Question 18

In ‘SOAP’, what is Assessment?

Answer 18

Impact of the issue; leads to a formulation about what to do and how to approach the change process (workers conclusion)

Question 19

In ‘SOAP’, what is Plan?

Answer 19

Specific goals and action steps (how to resolve/address client’s concerns)

Question 20

What are the standards for case notes/contact notes?

Answer 20

It must be handwritten and ONLY in black ink

Question 21

What are the 10 basic guidelines of record keeping?

Answer 21

1. Complete your records by word processing or handwriting them legibly. Legible handwriting is a MUST. What good is a daily log entry that no one can read?
2. Include date and time for all reports.
3. Do not use pencil or erasable pen. Records are permanent, so use something that cannot be erased.
4. Do not use ditto marks. → If you need to repeat a word, write it again.
5. Do not erase or use correcting fluid to correct mistakes. Different agencies have their own procedures for correction. Many require that you draw a line through errors and write “error” on that line or initial the error. The point is that erasures or covered-up errors have no place in a legal document, which is what records are.
6. Never sign for someone else. You are responsible for what is recorded under your name.
7. Leave no blank lines. Follow agency procedure by crossing out blank spaces, writing “N/A” (not applicable), and so on. In a record that you have signed, you do not want to leave blank spaces where someone else might add material.
8. Use exact details.
9. Spell correctly, especially when recording medications. Bad spelling destroys professional credibility and in some instances can be very dangerous.
10. No matter how informal the record, never refer derogatively to a client or use inappropriate language.

Question 22

What are the standard kinds of documentation for Case/ Contact notes?

Answer 22

Chronological

Question 23

What are the standard kinds of documentation for Narrative Summaries?

Answer 23

Monthly or quarterly