Record Keeping
| Author | Marilyn J. Samuels/Elayne M. Tanner |
| Pages | 88-104 |
Chapter
10
Record
Keeping
Records
are the
best
way a
social worker
can
document
and
justify
why
cer-
tain
decisions were made. Whereas memory
is
fallible, complete
and
accu-
rate
records stand
the
test
of
time
and can be an
invaluable asset
for the
social
worker, whose records
are
legal documents
and
must
be
treated
as
such. Fail-
ure to
keep records
in
accordance with
the
College's
standards
of
practice
is
a
serious breach
of the
standards
and may
result
in
disciplinary proceedings
against
the
errant social worker.
Principle
IV of the
Standards
of
Practice
Handbook
reads
as
follows:
The
creation
and
maintenance
of
records
by
social
workers
and
social
service
workers
is an
essential component
of
professional practice.
The
process
of
preparation
and
organization
of
material
for the
record
pro-
vides
a
means
to
understanding
the
client
and
planning
the
social work
and
social
service
work
intervention.
The
purpose
of the
social
work
and
social service work record
is to
document services
in a
recognizable form
in
order
to
ensure
the
continuity
and
quality
of
service,
to
establish
accountability
for and
evidence
of the
services rendered,
to
enable
the
evaluation
of
service quality,
and to
provide information
to be
used
for
research
and
education. College members ensure that records
are
cur-
rent, accurate, contain relevant information about clients
and are
man-
aged
in a
manner that protects client privacy.
A.
Record
Content
and
Format
The
Handbook's
interpretation section
for
Principle
IV is
divided into three
parts:
record content
and
format,
record maintenance,
and
access
and
disclo-
sure.
88
RECORD KEEPING
89
4.1
Record Content
and
Format
4.1.1 College members keep systematic, dated,
and
legible records
for
each client
or
client system served.
4.1.2
The
record reflects
the
service provided
and the
identity
of the
service provider.
4.1.3 College members document their
own
actions. College members
do
not
sign records
or
reports authored
by any
other person.
The
exception
is the
co-signing
of
records
or
reports
when
the
College member
is
acting
in a
supervisory capacity.
4.1.4 Information
is
recorded when
the
event occurs
or as
soon
as
pos-
sible thereafter.
4.1.5 Recorded information conforms with accepted service
or
inter-
vention standards
and
protocols
and is in a
format that facili-
tates
the
monitoring
and
evaluation
of the
effects
of the
service/intervention.
4.1.6 College
members
may use
documentation
by
exception
system
provided that
the
system permits
the
total record
to
capture
the
minimum content
as set out in
Footnote
3 [of the
Handbook].
B.
Why
Complete
Records
are
Necessary
The
importance
of
good records cannot
be
overemphasized.
It is
imperative
that
the
social worker's records provide
an
accurate
and
complete picture
of
his or her
interactions with clients. This
is
critical
for the
well-being
of
both
social workers
and
their clients,
as the
Angie Martin case
of
1997 dramati-
cally
demonstrated. Martin
was the
first
professional social worker
in
Canada
to
be
charged with criminal negligence causing death,
a
charge
that
carries
a
maximum
sentence
of
life
imprisonment.
As an
employee
of the
Catholic
Children's
Aid
Society
of
Toronto,
she was the
intake worker
for
Jordan
Heikamp,
who
died
of
starvation
at
five
weeks
of age
despite
the
interven-
tion
of the
children's
aid
society
and the
fact
that
he
lived with
his
mother
in
a
government-funded shelter.
After
being charged
and
strip-searched,
Martin
was
required
to
attend every
day
of a
seven-month preliminary inquiry.
At the
subsequent
coroner's
inquest,
during
which
she was on the
stand
for
four
days,
she was
cross-
examined
by
eight lawyers.
One of the
critical recommendations
that
came
out
of
this inquest,
in
spite
of the
fact
that
it
would have seemed obvious,
was
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