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29 Cards in this Set
- Front
- Back
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5 Categories of Clinical Documentation
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Intake
Social Assessment Treatment Plan Progress Notes Termination forms |
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Why social work records are important
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1) To enhance service delivery by monitoring our progress
2) To ease communication (with clients, supervisors, other agencies, courts) 3) To account for services and document needs (important for internal confidentiality and funding) 4) To meet the needs of supervision and administration (record review) 5) To contribute to research |
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3 Methods of Business Correspondence
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Memos
Letters E-Mails |
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Purposes of Business Correspondence
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Clearly communicates information
Establish effective human relationships |
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Ethics Related to Privacy
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Confidentiality
Abridgment Access Anonymity |
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3 Components of Effective Business Correspondence
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Mechanics
Empathy Organization |
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Deductive Writing
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Main idea first, followed by supporting details
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Inductive Writing
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Supporting details first leading to the main idea
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Netiquette
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Avoid using all capital letters
Be cautious about using humor and sarcasm Remember the email you send to one person may be forwarded to another person with your name appearing as the originator Do not over use priority flags Be aware of agency policies on emails If you mistakenly receive an email intended for someone else, inform the sender about the mistake and/or forward the email to the intended recipient |
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Criteria for Effective Recording
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Brevity
Clarity Accuracy Selectivity Retrievability Usefulness |
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Guidelines for Effective Recording
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Consideration of connotations
Watch slang and colloquialisms Watch use of uncommon words Consider the professional term Watch highly subjective words Be careful of how diagnostic labels are used Avoid the use of trite phrases |
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Sentences
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Brief - 20 words or less
Avoid use of compound sentences Use active verb structures |
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Paragraphs
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Each one should focus on a single idea
First sentence should state the central point 2 sentences minimum Don't cram too many ideas into 1 paragraph |
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Areas of Caution in Recording
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Political info
Religious info Intimate, personal info Extreme details regarding physical illness Hearsay Highly incriminating info Details about problems in contacting other professionals |
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Impacts of Managed Care on Practice
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Mechanisms to control treatment costs
Influences of managed care on intervention Influences of managed care on clinical documentation |
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Good Release of Info Forms
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Who
What Purpose Expiration date Signatures Agency policies on confidentiality |
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Treatment Plan
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Problems/Symptoms
Goals/Objectives Strategies |
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2 Styles of Progress Notes
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1. Narrative/Summary style (paragraph form)
2. Problem-oriented style - SOAP - NAP |
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Termination Forms
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Discharge summaries
Termination letter |
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Ethical Accountability in Recording
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Legal - record retention
Fiscal (financial) - records demonstrate effectiveness Clinical - privacy and confidentiality in client records |
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Client Right to Self-Determination
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Client has the right to access their records
Release of information |
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HIPAA Laws
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Health Insurance Portability and Accountability Act
- electronic transfer of information |
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Federal Privacy Act of 1974
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Buckley Amendement
Gave clients the right to access agency records |
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3 Questions to Ask When Organizing a Letter
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1. What will be the central idea?
2. What will be the most likely reader reaction to the message? 3. In view of the predicted reader reaction, should the central idea be addressed first or later in the letter? |
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3 Major Sections of Business Correspondence
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Introduction
Body Closure |
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Responses to E-Mails
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Acknowledge the receipt of an email
Answer promptly or indicate when you can answer Read the entire message first. Some writers bury important information Answer all questions completely Comment directly in the sender’s message if appropriate. (Use a different font or color to distinguish your response. |
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Characteristics of Good Documentation
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• Based upon the nature and policies of the unique agency and takes into account unique characteristics of the agency.
• Documents adherence to agency policy and practice/supervisory guidelines. • Includes critical information to guide best practice. • Well-written, well-organized and legible. • Comprehensive and up-to-date. (make time to record notes properly!) • Follows the agency’s policy for making corrections. (draw a line through the mistake and write the correction over it, then sign) • States the rationale and evidence for decisions. (for protection of social worker) • Documents the client’s involvement in treatment planning and decision making. (the client needs to be involved!) • Offers a comprehensive and coherent presentation of services from in-take through follow-up. |
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Categories of Functional Impairments
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Occupational
Academic Social Affective Physical Combination |
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Informed Consent Forms
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My responsibilities
Your responsibilities Financial info Missed appointments Grievances |
