SOCIAL WORK DOCUMENTATION AND COMMUNICATION
I.
II.
Interviewing Techniques
Clarifying Questions- A skill that enables the social worker to
seek specificity on what the client is thinking, feeling, and
experiencing. Asking for examples, specifying the meaning of
words
Paraphrasing- The content of the message is emphasized as
a way to communicate understanding to the client. You restate
the clients message, using your own words.
Furthering- Workers covers areas in a clients live that require
more in-depth review
Reflecting Feelings- The social worker uses reflection of
feeling to restate and explore the clients affective (feeling)
messages
Summarizing- This skill enables the social worker to pull
together key ideas and themes regarding the most important
aspects of the clients problems, and also provides focus and
continuity to the interview.
Information Giving- The social worker often provides useful,
relevant, up to date and information to the client.
Confronting- Skill that enables the social worker to point out
message discrepancies to the client.
Interpreting- A skill that enables the social worker to go
beyond the stated problem and begin to delve more deeply.
Interpretation can provide the client with an alternative way of
viewing the problem.
Silence- Many interviewers are uncomfortable with silence and
feel the need to keep the communication flowing. However,
there are benefits to allowing silence:
-Allows interviewer and interviewee to process information.
-Can also be used to allow for de-escalating a situation.
Pitfalls to Avoid in Interviews
1. Advice Giving not consistent with a co-equal collaborative
relationship
2. Inappropriate use of humor minimizes the problem
3. Interrupting the client system does not allow the system to
express the complete idea or finish the train of thought
4. Abrupt transitions do not allow for closure on a topic that the
client system has chosen to discuss
5. Inappropriate and irrelevant questions move the professional
interview away from a collaborative approach toward an intrusive
and investigative style of communication
6. Judgmental responses impede the development of trust by
placing the generalist social worker in a role of authority
7.
III.
IV.
Offering false assurance minimizes the problem and prevents the
client system from coming to terms with the difficulty and
consequences of the situation.
8. Inappropriate social worker self-disclosure takes the focus off
the client system and distracts from client system concerns
9. Premature confrontation may hinder the development of trust and
interfere with the development of the professional relationship.
10. Overwhelming the client with too much information confuses
critical issues and inhibits decision making and action
11. Premature problem solving is a barrier to achieving complete
understanding of the complex psychosocial issues brought by the
client system and bars the client system from fully exploring the
issue and participating in the strength based problem solving efforts
12. Insincerity is a form of dishonesty and creates an artificial helping
relationship
13. Minimizing the problem is an effort to downplay the depth,
breadth and complexity of the situation and is antithetical to the
helping process. It does not give the message that the client is
understood.
Effective Telephone Communication
The task of communicating over the telephone has to be
accomplished by your voice.
When making and receiving calls, always fully identify you by
name, organization, and department.
Jot down the major points you wish to cover before placing the
call.
If the person on the other end is talking at some length,
interject a brief comment at interval
Whenever possible, answer the telephone on the first or
second ring, and immediately respond to the caller.
If you must leave a message for a person you did not reach by
phone, keep the message short.
Establish a regular time of day to receive telephone calls.
Master the skills of using your agencys phone system such as
transferring calls, using voice mail, and so on.
The First Telephone Contact
Remember that during a telephone conversation, you cannot
read the clients non-verbal behaviour
If speaking with a voluntary client, briefly explore the clients
presenting concern or request so you can evaluate the
appropriateness of this referral to your agency.
If speaking to an involuntary client, it is usually best to confine
the phone conversation to arranging the first face-to-face
interview
Be aware of the clients relationships and roles
V.
When arranging the first office visit, make sure the client knows
the location of your office and your name. Some clients may
need guidance on how to use public transportation to reach the
agency.
Social Work Documentation
Documentation material that provides official information or
evidence or that serves as a record
Documentation of social work interventions with clients are
contained in one written record.
Ethical and Professional Aspects of Documentation
Do not document problem in stating or interdepartmental
issues
Know when communication is privileged and when it is not
Do not share information with those without a need to know
Protect client privacy, do not leave client information where
non-professionals may have access it
Recording is the process of capturing data or translating
information to a recording format stored on some form of
storage medium.
Social work recording has long been recognized as a vital
component of professional and competent practice in agency,
private, and community settings.
STANDARDS FOR SOCIAL WORK RECORDING:
Accountability to the client, the organization and to relevant
legislation.
Evidence of facts gathered, assessment, intervention and
outcome. On-going essential information.
A clear statement of social work involvement on an on-going
basis.
Relevant information for future social work involvement and
continuity of care.
Information about the role of social work in an interdisciplinary
team.
Documentation for the purposes of research and program
evaluation
USES OF RECORDS
Accountability to the client, the organization and to relevant
legislation
Evidence of facts gathered, assessment, intervention and
outcome
On-going essential information
Relevant information for future social work involvement and
continuity of care
Information about the role of social work in an interdisciplinary
team
Documentation for the purposes of research and program
evaluation
EDUCATING STUDENTS & OTHER PROFESSIONAL
Records are used to teach social work practice and agency
procedure
Used to introduce students and new workers to practice in the
organization
Important in the on-going education and development of each
practitioner
A clear statement of social work involvement on an on-going
basis
Supervisors use the record to teach workers on how to practice
and how to record
Used to educate members of other disciplines about what
social workers do and how they do it through reading social
workers record
Types of recordings & their purposes
PROCESS RECORDING
- Social Service Recording was used in 19th century
- Comprehensive process recording is a major learning
tool in social work
- A process recording is a written record of an interaction
with a client
- Beneficial when developing first case note
documentation because of the process and in-depth details
required
Purpose:
- Enhance self-awareness
- Improve assessment skills
- Learning to work effectively with clients
Steps in completing a narrative recording
CREATE many handwritten notes documenting everything that
was said (verbatim)
-It is important that you and your clients actions and nonverbal
behaviors are also logged
-Record interview details immediately when using this style of
documentation to ensure that everything is written down.
REVIEW your handwritten notes
-Prepare a summary of your work with your client
Strength: The practitioner learns to remember the service
transaction in detail. The record is a useful learning too.
Limitations:
-Time consuming and costly
-Does not teach recording skills needed for agency practice;
should be supplemented by other forms of recording
-Selective rather than duplicative; should be supplemented by
approaches which more accurately portray the encounter
SUMMARY RECORDING
After conducting a narrative recording, the SW will then
prepare a summary of his/her work with the client.
Keep all case
Maintan a
notes in one place chronological
record of activities
- Intervention is required to solve the problem; it is helpful
to use the S-O-A-P format.
Facilitate
summarization
PROBLEM ORIENTED RECORDING (POR)
- Formal that is widely used in health and mental health
settings
- it consist of four components
Components of POR
A. CLIENT DATABASE
- The identifying information collected during the intake
interview. Information should include:
Clients full name, including any aliases
Identifying number such as SS no., patient no., client no.
Interview date
Recording date
Your name as the Social worker
Purpose of the interview
B. LIST OF SPECIFIC PROBLEMS
- can be anything of concern to the clients, the social
worker or both
Each problem is assigned a number and described in
behavioral language
The problem list serves to focus case planning and
intervention
It should be logically related to a specific problem in the list.
As problems are resolved, they are removed from the list.
Resolved problems numbers are not reassigned, each
number is used only once.
C. ACTION DEVELOPMENT
- The type of reaction to each client problem in the list
There are three basic actions
Initiate intervention
Secure additional information to assist in understanding the
problem(s) better
Monitor the situation(s) and observe for further development
D. PLAN IMPLEMENTATION
Strengths:
Facilitates accountability; responsible for responding to the
problem listed.
Facilitates peer review, medical education and
interdisciplinary collaboration.
Limitations
Time consuming and costly
Must be adapted to incorporate salient social work issues
and interventions
ETHICS IN RECORDING
PLAN IMPLEMENTATION
When using the Problem-Oriented Recording (POR),
and intervention is required to solve the problem, it is
helpful to use the SOAP format
SUBJECTIVE INFORMATION-describes how the
client perceives his/her situation; cannot be validated
OBJECTIVE INFORMATION-derived from
professional staff; can be verified and validated
ASSESSMENT- Using both the subjective and
objective information; Social Worker can now assess
the problem
PLAN- How the Social Worker and client intend to
address and/or resolve the problem
ETHICAL AND PROFESSIONAL ASPECTS OF
DOCUMENTATION
Do NOT display bias.
Do NOT engage in defamation of character.
Do NOT tamper with or alter records and do NOT use
dittos, erasure, or write out in your documents
Do NOT document interventions before they occur.
AVOID documenting professional disagreements
(jousting).
Do NOT document problems in staffing or
interdepartmental issues.
VI.
VII.
Know when communication is Privileged and when it
is not
Do NOT share information with those without a need
to know
Protect client privacy
Do NOT leave client information where
Non-professionals may have access to it.
GUIDELINES IN RECORDING
KEY ELEMENTS OF DOCUMENTATION:
Write just enough to make your point. Include enough but
not too much detail.
Do NOT over document with irrelevant detail.
Use correct grammar and spelling. Lack of writing skill
lowers your credibility.
Print or write legibly.
Document what you know (like direct observation), not
what you think.
Be specific and avoid characterizations, like poor
outcome, good result, moderate compliance, drunk,
aggressive, combative
Document in a timely fashion to preserve accurate
recollection.
Avoid acronyms and abbreviations unless they appear on
approved list
Use precise description and specific language.
Avoid vague language or ambiguity. Vague language
includes phrase such as:
It seems, I suppose, It appears, I believe, I feel,
and the like.
TECHNICAL WRITING SKILLS IN SOCIAL WORK PRACTICE
Memorandum
A short message or record used for internal communication in
a business.
An effective memo, says Barbara DiggsBrown, is "short, concise, highly organized, and never late. It
should anticipate and answer all questions that a reader might
have. It never provides unnecessary or confusing information"
The following guidelines will help you structure a memo:
Use a clear subject line.
- State your purpose in the first paragraph.
- Summarize any potential objections.
- Keep the paragraphs short.
- Use subheads between paragraph groups.
- Use bulleted and numbered lists.
- Request action.
PURPOSE: Memos are used within organizations to report
results, instruct employees, announce policies, disseminate
information, and delegate responsibilities.
Format of Minutes of Meeting
Meeting minutes are the written or
recorded documentation that is used to inform attendees and
non-attendees about what was discussed and what happened
during a meeting.
Format of Minutes of Meeting:
-Name of the organization
-Kind of meeting
-Date and day of the meeting
-Venue of the meeting
Presiding Officer
-Call to Order:
-Name of those Present and Absent
-Reading of the Minutes of the Past Meeting (Attached the
original minutes)
-Questions/ Corrections and Approval of the Minutes Read
-Reports of the Committee (if any)
-Agenda/ Topics Discussed
-Agreement Made or Reached
-Adjournment
Prepared by: (Secretary)
Concurred by: (President)
Date: _____
Date:
________
Referral Letter
Referral means putting people in touch with services that have
the resources to help them achieve their goals.
When we make a referral, we are basically sending a person to
another professional who specializes in working with particular
needs or problems.
Steps in making referral letter:
SOLICITATION LETTER
Are necessary in fund raising campaigns, as they are written to
attract people and organizations for their contribution to an
event of campaign.
Are directly written to the specific donors and supporters.
Purpose: To secure funds from the community to support a
special project or the on-going work of a social agency.
The major aspects that need to be included in a solicitation
letter are:
-The purpose solicitation letter
-Mention the target of fundraising
-Details of donation forms and submission
Note: A good donation solicitation letter format should be
concise, informative and clear. It must include the person or
organization that is requesting for the donation, the cause of
the donation and what is requested as the donation.
Professional diary
Purpose: share ones knowledge with colleagues in order to
strengthen the quality and effectiveness of social work
practice.
A professional journal is a log of events that take place within
your workday.
The focus of a professional journal is tracking what you have
worked on, and what you are working on.
A professional journal can include your "thought processes" as
you handle each day's tasks, and even record your ideas and
epiphanies as they occur during the course of work.
A large part of the knowledge we accumulate in our careers
remains untapped because we never write it down.
Professional journal writing software allows us to tap that
resource and learn from our own mistakes and successes.
Format:
Date: ________
A. Experiences (activities, events, feelings, problems
encountered, actions taken etc.)
B. Application of Theories/ Concepts
C. Critical Reflections and Learning Insights
Prepared by:
_________________
Name and Signature
Noted By:
____________________________
Name and Signature of Supervisor
Case study report
Case study refers to the collection and presentation of detailed
information about a particular participant or small group,
frequently including the accounts of subjects themselves. A
form of qualitative descriptive research, the case study looks
intensely at an individual or small participant pool, drawing
conclusions only about that participant or group and only in
that specific context.
Case Study Format:
-Identifying Information
-Family Composition
-Description of the client (include bio-psycho social and
spiritual formation)
-Problem Statement
-Background Information
a. Family Background
b. History of the childs current difficulty/situation
(specify)
-Assessment (based on facts, associated with the different
theories that will explain the behavior of the child victim of
disaster)
-Treatment Plan / Intervention
-Recommendation
-Attachments (e.g. Birth Certificate, medical exam results,
psychological support, legal affidavits, copy of the complaint
Accomplishment report
Accomplishment report is a regularly prepared status report
that provides an overview of what was achieved during the
given period.
Specific information related to team work progress, goals
established and achieved, problems arisen and decisions
made, and descriptions of unplanned activities are covered by
the report.
Format: Date:
1. Accomplishments
Narrative presentation of both quantitative and qualitative
accomplishments; use tables, diagrams/ charts, etc. in your
discussion.
[Link]/ Concerns and Actions Taken
3. Recommendations
Prepared by:
_____________________
Social Worker
Noted by:
_____________________
Supervisor
