For the Record
By David Hage, PhD, MSW, LCSW, ACSW, C-ASWCM, CDP
Social Work Today
Vol. 23 No. 4 P. 16

Strategies for Promoting High-Quality Ethical Social Work Documentation

When we think of documentation, different thoughts, feelings, and past scenarios may come to mind based on our wide-ranging experiences, places of employment, and various legal and other regulatory requirements. Most social workers have entered the profession to help others, not to dedicate the majority of their work time to documentation. While the motivation to serve the needs of various client systems is a noble aim consistent with core social work values, it does not dismiss the necessity to appropriately complete documentation in a timely, ethical, and accurate manner.

During the early stages of the social work profession, documentation predominantly served the purpose of supporting theory and aiding in research and educational activities. Social work documentation later served to detail important aspects of case management and clinical work. More recently, it also serves an important risk-management function; to protect clients, practitioners, and agencies from potential legal, regulatory, and ethics complaint liabilities.1

Documentation can, at times, cause us to not want to do aspects of our work or can delay the completion of other important domains of social service work. Frequently the connotations concerning documentation may center on negative circumstances. We may have heard of a colleague’s professional documentation challenges or documentation being overly burdensome or hard to maintain in a timely manner. An omission or documentation error may have been identified by a staff auditor or a regulatory reviewer where we have worked, and the consequences may have been a source of stress. Some of our colleagues may have even chosen to leave a work environment due to excessive documentation demands or insufficient time to complete documentation. The adages associated with documentation, such as “if you didn’t document it, it didn’t happen” or “cya all the way,” likely are also readily in mind.

While there are certainly many challenges associated with documentation, there are also many positive benefits of high-quality documentation. When done well, documentation is an opportunity to create an accurate and nonjudgmental record that generally includes a history, assessment, and plan to address the reasons for service. Documentation helps us track progress, plan for termination, and evaluate practice effectiveness. When done properly, high-quality documentation can serve many beneficial purposes, including but not limited to serving as a justification of clinical reasoning, a point of reference for the documenter, a communication tool between care providers, and a way to prove legal and regulatory compliance. Good documentation can also be a direct asset to the client involved in the services being documented. For example, a client may rely on social service documentation to justify gaining access to insurance benefits, obtaining new services, and appealing service denials or to better understand a problem or the social work practitioner’s rationale for service planning.

Beginning From an Ethical Frame
There can sometimes be an insufficient emphasis on social work documentation in busy practice environments. Positive recognition for completing documentation well, on time, and ethically is as critical as pointing out opportunities for improvement. “Careful and diligent documentation enhances the quality of services provided to clients and, ultimately, can protect practitioners.”2 Ensuring that documentation is consistent with established standards found in the 2021 NASW Code of Ethics is essential to high-quality social work documentation. The Code of Ethics identifies underlying values, ethical principles, and explicit practice responsibilities, which include guidance for approaching client records. The first value underlying quality documentation is integrity.3 Thus, social workers have a duty to complete documentation with veracity. The associated ethical principle of acting in a trustworthy manner describes a duty to act honestly and promote ethical practice with the knowledge that social workers represent themselves as professionals, the organizations they are affiliated with, and the broader profession itself.3 The ethical value of competence also relates to social work documentation as detailed in the proceeding resource and technology sections that follow.3 The associated ethical principle admonishes social workers to practice within areas of competence and to continue to develop professional aptitude, including performing documentation appropriately. This includes using related documentation technology products as per related requirements and professional best practices. In the Code of Ethics, standard number 3, Social Worker’s Ethical Responsibilities in Practice Settings, client records are a specific point of focus. Social workers are advised to ensure that documentation is accurate and timely to ensure continuity of service and protect clients’ privacy. Social workers should also store records following termination so that the documentation can be accessed as appropriate in the future, as consistent with relevant laws, policies, or contractual obligations.3

Resources for High-Quality Documentation
The NASW Press offers three texts dedicated to documentation that social workers can consult to enhance their documentation quality. Social Work Documentation, 2nd Ed. Aims to help social workers strengthen case recording skills. Clinical Social Workers in Private Practice is a resource for private practitioners that includes a section on documentation and record keeping. And Retiring or Closing a Private Practice, a guide to ending one’s own practice, addresses related documentation recommendations. Reamer advises that social workers should consider a number of valuable approaches to conducting an ethics audit as a risk management strategy.4 This audit resource provides a pathway to identify potential ethical issues, evaluate the effectiveness of current approaches to ethics issues, and make appropriate changes and monitor them. This ethical audit strategy involves assessing various important documentation items, such as notes, consent forms, critical incident reporting, referrals, notation of failed or canceled appointments, clarity of payment expectations, and other relevant internal and external documentation.

Emerging Technological Documentation Considerations
Since the emergence of electronic documentation, new considerations concerning documentation have emerged. Accordingly, NASW partnered with the Association of Social Work Boards, Council on Social Work Education, and Clinical Social Work Association to form the Technology Standards Task Force. Over a two-year period, this group evaluated the social work technology literature, related statutes, and licensing regulations, resulting in the publication of the Standards for Technology in Social Work Practice after integrating relevant stakeholder comments and feedback. Some key documentation-related takeaways that emerged from this task force include standard one, which addresses ethical and values-based obligations concerning the provision of information to the public. The use of public websites, blogs, social media, and other forms of electronic communication is discussed. In section 1.02, social workers are encouraged to periodically review the accuracy and validity of online information, including credentials. Standard number two includes an emphasis on the design and delivery of services, including the ethical uses of technology, ensuring clients understand the risks and benefits of technology (eg, the potential risks of breaching electronic records and safeguards that will be put in place to prevent this from occurring). Standard number three covers gathering, managing, and storing information, including access to records within organizations, accessing one’s own records, and accessing records remotely, for example. Standard number four focuses on the use of technology in social work education and appropriately supervising how social work students utilize technology, including that related to documentation. This standard promotes the importance of providing training to use documentation-related technology.

Educational Considerations
The educational context of documentation requires discussion as well. With the rapid advances in technology, it’s worth considering if sufficient educational resources are available to students and practitioners who are increasingly becoming involved in the transition from handwritten to electronic documentation. The 2022 Council on Social Work Education Educational Policy & Accreditation Standards describes an important component of ethical and professional behavior as involving written communication.5 The NASW Standards for Technology in Social Work Practice6 describe the responsibility of educators and practitioners to provide education about technology and documentation and to provide opportunities for students to receive related supervised training. However, many social service agencies and health care facilities employing social workers operate under accreditation and insurance reimbursement agreement contracts, which may limit students’ ability to practice actual handwritten or electronic documentation in a client record during internships. There’s also clearly an important difference between academic paper writing and practice-focused documentation across the care continuum. In addition, national high school seniors (incoming social work students) have recent reading scores that decreased by two points compared with 2015 and seven points compared with 1992.7 The writing scorecard for the last National Center for Education Statistics data collection was limited due to a change in assessment format, but anecdotal evidence and this professor’s teaching experience seem to suggest additional challenges with general academic and practice-focused writing as well. Given these realities, practice-focused documentation simulation and other creative documentation teaching pedagogies remain important points of focus for continued development in the social work classroom, field, and research arenas.

Mistakes, Shame, and Moving Forward
In the landmark report “To Err Is Human: Building a Safer Health System,” the Institute of Medicine sought to raise awareness of and reduce medical errors. This emphasis on recognizing human imperfection, owning error, and replacing it with planned and monitored improvement is an important lesson for social workers in various social service settings. This most certainly applies to social service documentation as well. Of equal importance to recognizing the human potential for error is the second half of Alexander Pope’s quote, “to forgive is divine.” The book Shame and Social Work addresses theory, reflexivity, and practice informed by current social worker and social work student research. In chapter nine, the relationship between shame and error is examined. As making a mistake is both a factual and emotional event, criticisms of error should also simultaneously include chances to learn from mistakes and correct future actions where possible.8 It’s true that the impact and consequences of documentation errors can vary in significance ranging from a minimally consequential error to an error causing client harm and/or a violation of ethical principles or law. Refamiliarizing ourselves with the discussed NASW standards, publications, and other resources can be of great value in increasing the potential to create documentation that’s ethically sound and of a high-quality, thus also reducing social work practitioner and agency liability.

— David Hage, PhD, MSW, LCSW, ACSW, C-ASWCM, CDP, is a gerontologist, a licensed clinical social worker in Florida and Pennsylvania, and an allied health sciences educator. He’s an assistant professor and director of field education at Misericordia University Social Work Program, where he coordinates the undergraduate gerontology minor with the social work department, directs the postgraduate Geriatric Care Management Certificate within the occupational therapy department, and is faculty liaison for the university’s Institute on Aging.

TIPS FOR REDUCING DOCUMENTATION ERRORS
1. Review relevant documentation guidance at least annually. For example, review the NASW Code of Ethics, relevant related documents like the NASW Standards for Technology in Social Work Practice, statutes (eg, HIPAA), and other regulatory documentation guidance (eg, CMS Guidelines for Coding & Reporting) to ensure accurate understanding of documentation requirements.

2. Clarify the purpose of the document that you are undertaking and potential audiences. For example, take the time to consider if the purpose of the planned documentation is to record a new client history and assessment, a progress note, or a collateral contact. Consider who might read this document. Various stakeholders may view the document, for example a colleague, a supervisor, an internal auditor, an external reviewer, a billing professional, or a client. Considering who the document may reach might require you to modify the way it is written. For example, knowing a client may read the document might increase your objectivity. Or knowing your supervisor might read it could influence its length, your use of third-person language, approved abbreviations, and compliance with agency policies related to documentation.

3. Ensure that appropriate guidelines and standards are followed. See item number one. Another good question to ask here is, would those who might view this document (see item number two) find the content accurate, nonjudgmental, inclusive of all required content (meeting statutes, regulations, policy, and procedure standards), and excluding unnecessary content (personal judgments, and excessive, unnecessary, or redundant information)?

4. Double-check your accuracy. This might include re-reviewing your note after completion to evaluate for any possible errors. For more difficult cases or situations, you may wish to seek consultative guidance to ensure all details are appropriately addressed. Additionally, you or another qualified agency designee may choose to audit a certain number of records at specified intervals of time (often weekly or monthly) to assess accuracy and identify performance improvement opportunities.

5. Continue to be a student. Enhancing your competence in writing and your area of practice can help you to create better documentation, as can keeping up with relevant documentation requirements and changes. Strategies to achieve this aim might include attending documentation-related continuing education sessions, seeking supervisory guidance, professional mentorship, and reviewing periodic updates and guidance from relevant stakeholders, such as legal entities, accrediting bodies, and other professional associations.

References
1. Reamer FG. Documentation in social work: evolving ethical and risk-management standards. Social Work. 2005;50(4):325-334.

2. Reamer FG. Never underestimate the power of documentation. Social Work Today. October 29, 2001. https://www.socialworktoday.com/news/eoe_102901.shtml

3. National Association of Social Workers. Code of Ethics. https://www.socialworkers.org/about/ethics/code-of-ethics. Published 2021.

4. Reamer FG. The social work ethics audit: a risk-management strategy. Social Work. 2000;45(4):355-366.

5. Council on Social Work Education. 2022 EPAS educational policy and accreditation standards - CSWE. https://www.cswe.org/getmedia/94471c42-13b8-493b-9041-b30f48533d64/2022-EPAS.pdf. Published 2022.

6. National Association of Social Workers. Standards for Technology in Social Work Practice. https://www.socialworkers.org/Practice/NASW-Practice-Standards-Guidelines/Standards-for-Technology-in-Social-Work-Practice. Published 2017.

7. National average scores. The Nation’s Report Card website. https://www.nationsreportcard.gov/reading/nation/scores/?grade=12. Published 2022.

8. Sicora A. Shame, Mistakes and Reflective Practice in Social Work. In: Frost L, Magyar-Haas V, Schoneville H, Sicora A, eds. Shame and Social Work: Theory, Reflexivity and Practice. Bristol University Press; 2020:187-204.