Imagine you are working with an established client. The clients appointment is late in the evening, and you are tired when

Enhancing Student Awareness of the Importance of Full and Accurate Documentation in Social Work Practice Riki Savaya

The paper describes a classroom assignment that was used to raise social work students’

awareness of the importance of timely, clear, and thorough documentation. The assignment was devised in view of the great importance of quality documentation in social

work, coupled with the reluctance of social workers to invest the necessary time and effort to produce it. The core of the assignment was for the students to examine and report on the

documentation in two client files at their fieldwork agency. The findings obtained from the students’ reports show that about a fifth of the 190 files that were examined did not contain various pieces of basic information about the clients and intervention outcomes,

and that much of the information that was provided was unclear and unorganized. The students’ written reflections following the completion of the assignment indicate that the

assignment achieved its aim of elevating their awareness of the importance of quality documentation. The paper ends with a discussion of issues to consider in repeating the

assignment in the future, based on the reflections of the students and their classroom instructors.

Keywords: Documentation; Recording; Client Files; Social Work Students; Students’ Awareness

Introduction

Clear, regular, and thorough documentation is vital to key aspects of social work practice (Cumming et al., 2007), including orderly transfer of cases between workers;

planning and implementation of systematic, evidence based intervention; and intervention monitoring and evaluation (Bloom et al., 1995; Kagle, 1995; Gibbs, 2003;

Luepker, 2003; Reamer, 2005; Foster et al., 2008). In the last two or so decades,

ISSN 0261-5479 print/1470-1227 online q 2010 Taylor & Francis DOI: 10.1080/02615470903552006

Correspondence to: Professor Riki Savaya, Shapell School of Social Work, Tel Aviv University, Ramat Aviv, Tel Aviv

69978, Israel. Email: [email protected]

Social Work Education Vol. 29, No. 6, September 2010, pp. 660–669

accountability and risk management have been added to the functions of

documentation (Gelman, 1992; McAuliffe, 2005; Reamer, 2005; Cumming et al., 2007). Both the accountability increasingly demanded by funding agencies and the

culture of litigation, which has issued in a degree of defensive practice, make quality documentation necessary; so will the likely introduction of mandatory performance

measurement, which entails regular reporting on the inputs, outputs, and outcomes of interventions and programs, into social work agencies (Kusek and Rist, 2004;

GAO, 2005). Moreover, given the many and changing functions of documentation, there has

been considerable discussion of the appropriate content and level of detail of service records, as well as variations over time and place (Reamer, 2005). Traditional records

documented the evolution of the worker’s diagnostic thinking and the development of

the client’s self-knowledge and social competence. More recent records are more narrowly focused on the definition and remediation of specific problems or needs.

Workers select and organize information to highlight and link the need for service, service goals and plans, service activities, and the impact of service on the client’s

situation (Kagle, 1993). Today, quality documentation is considered so important that the requirement for it is anchored in legislation and policy, and various national

associations of social workers cite the need for accurate, sufficient, and timely documentation in their ethical codes (see, for example, the US National Association

of Social Workers, the British Association of Social Workers, and the European Association of Social Workers). The introduction of electronic documentation in

recent years in no way obviates the need for quality recording, since, even here, workers are generally required to enter textual accounts of the intervention process

and outcomes. Most social workers, however, view documentation as a bureaucratic imposition

that has little relevance to their work, client needs, or service provision, or as a necessary evil that takes precious time from more pressing work (Ovretveit, 1986;

Kagle, 1991, 1993, 1995; Gelman, 1992; Prince, 1996). As a result, documentation is given low priority by workers (Gelman, 1992; Kagle, 1993; Reamer, 2005), and is often

resented, poorly written, and not kept up to date (Edwards and Reid, 1989; Kagle, 1991, 1993; Cumming et al., 2007).

Many contributory factors feed into the negative attitude towards and neglect of documentation. These include the proper focus of social work on helping clients, the

great pressure of agency work as a result of large caseloads and frequent emergencies, and lack of managerial directives regarding the purpose of the documentation, the

information to record, and who the records are for (Edwards and Reid, 1989; Kagle, 1993). There are also psychological impediments. Workers may avoid the hard work of

recording tasks that require them to think about the case and what they are doing and why, and shy away from writing down clearly defined objectives, as this would allow

them and others to measure achievements against intentions and may mean facing up to their limitations and what can realistically be achieved (Ovretveit, 1986). The

negative attitudes and neglect may also be anchored in the limited attention given to documentation in social work training programs (Gelman, 1992). Kagle (1995) points

Social Work Education 661

out that social work students are first introduced to record keeping in fieldwork and

suggests that social work education may prepare future practitioners more adequately by directing classroom attention to record keeping.

This paper discusses a classroom assignment that was used to raise student awareness of the importance of timely, clear, and thorough documentation in practice.

The assignment was given to students in their last year of the BSW program at the Bob Shapell School of Social Work at Tel Aviv University. This is a three year program that

qualifies graduates to work as licensed social workers (Savaya et al., 2003). Until the assignment was given, no course or section of the curriculum was explicitly devoted to

the subject of documentation. During their fieldwork students are required to fully document every meeting with clients. This documentation, however, serves as a tool

for intervention training and generally consists of word by word reproduction of the

meetings. It is unrealistically time consuming for agency work, as well as very different from the systematic, focused, and yet condensed documentation required for

professional practice. The hope was that the assignment would get the students to internalize the importance of proper documentation, so that as professionals they

would continue to document their work in a full, timely, and systematic fashion despite the intense contending pressures of agency work.

The assignment was given in the mandatory Intervention Evaluation course that all social work students must take in their third year. The immediate impetus for the

assignment was the understanding that proper documentation was essential to evaluating the implementation and outcomes of interventions. The assignment took

advantage of the highly integrated nature of the BSW program at the Bob Shapell School of Social Work, especially between the mandatory Social Work Methods course

and the students’ fieldwork training. Both the Social Work Methods course and the field training run over all three years

of the program, with each year’s content built on and adding to that of the year preceding it. Fieldwork training starts at one day a week in the second semester of

the first year and continues at two days a week in the second and third years. During their fieldwork, students are exposed to a variety of populations, problem

areas, intervention approaches, and learning opportunities at different social work agencies and services. Each student is supervised by a fieldwork supervisor, with whom

he or she meets once a week for an hour and a half at a time to discuss his or her cases. Each supervisor provides individual supervision to two students each year.

Each year, the fieldwork is carried out in the framework of the concurrent Social Work Methods course. Students apply the assessment and intervention methods

taught in the course to their fieldwork cases, and their fieldwork experiences are regularly discussed in class. Moreover, the classroom instructors are in regular contact

with the students’ fieldwork supervisors. They receive regular updates from the supervisors on the students’ performance and work with both the supervisors and the

students to resolve any problems that arise in the fieldwork. The core of the assignment was for the students to examine and report on the

documentation in their fieldwork agencies. The paper describes the key parts of the assignment, the students’ findings, and the educational benefits and problems of

662 R. Savaya

the assignment as reported by the students and their classroom instructors.

It ends with a brief discussion of issues to be considered in giving the assignment in the future.

The Assignment

The assignment was given at the start of the first semester of a required year-long Evaluation of Interventions course and coincided with the beginning of the students’

fieldwork. It was given as part of students’ orientation in their fieldwork agency, before they started seeing clients. Every year, during orientation to their new agencies,

students read a number of client files, with the client’s name anonymised, so as to become acquainted with the agency’s service users. In preparation for the new school year, the Evaluation of Interventions instructors decided to use this component

of the orientation to try to raise the students’ awareness of the importance of documentation. Their first step was to ask the instructors of the Social Work

Methods courses to approach their students’ fieldwork supervisors and ask them to permit the students to do the assignment using two of the files they read during

their orientation. For the purpose of the assignment, documentation was operationalized as the

information recorded over the entire course of the intervention on client features and problems, intervention components and processes, as well as on inputs, outputs, and client changes. The main part of the assignment was for the students to extract specific

data on each of these categories from two client files and to record the information on structured forms especially designed for this purpose.1 Where information was

missing, the space allotted for it was to be left blank, so that the students could see what was documented and what was not.

The client features listed on the form included the client’s identity (an individual, couple, family, organization, or community); socio-demographic features (gender,

age, place of birth, years of residence in Israel, religion and religiosity); socio-economic status, including any welfare benefits received; and physical and mental health.

Information about the number of years in Israel and about religion and religiosity are deemed important in Israel to being able to provide culturally sensitive intervention for the many immigrants in the country and for persons belonging

to groups with particular religious restrictions (e.g. religious Arab women and ultra-orthodox Jewish women will not meet alone in a closed room with a male

social worker). The form listed 10 different problems, including economic, emotional, behavioral,

developmental, interpersonal, and other problems. The students were asked to mark those that were addressed in the intervention and to note the information the file

contained on them. They were also asked to record any documentation of the clients’ perceptions of their problems.

The intervention components and processes included the professionals or agencies

that collaborated in the intervention; the levels of intervention; the main intervention strategies; and the stages, resources (e.g. diagnostic tests, client training, daycare

Social Work Education 663

payments, etc.), outputs, and duration of the interventions. The students were also

asked to indicate whether the documentation indicated the social worker’s reasons for choosing the interventions, factors that facilitated or impeded the intervention, and

turning points in the intervention. For the documentation of outcomes, the form returned to the problems listed

earlier and rephrased them as outcomes—for example, improved economic status, improved emotional status, and so forth. For each outcome, the students were asked

to extract three pieces of information: (1) the operative definition of the expected outcome; (2) whether the outcome was achieved, fully, partially, or not at all; and (3) the documentation that enabled the students to draw conclusions as to the

outcome achievements. At the end of the form, space was left for the students to add any other information

in the file that was relevant to understanding the intervention processes and outcomes. The expectation was that the students would learn both from their own

investigations of their files and from the aggregated ‘findings’ of the other students. To this end, the percentages of files that contained each piece of information were

computed and the students given the findings.

Written Reflections on the Assignment

To evaluate the assignment, written reflections on the assignment were obtained from both the students and the Evaluation of Interventions instructors. The students were asked to write a personal statement indicating what they had learned from the

assignment and how they thought they would apply their knowledge in their professional work.

The instructors were asked to answer the following questions in writing:

(a) What, if any, contribution did the assignment make to the instructional process?

(b) What, if any, difficulties did the assignment pose for you and your students? (c) How did the field supervisors react to the assignment?

(d) Do you have any recommendations for improving the assignment in the future?

Basic content analyses were conducted on all reflections by the author of the

paper. The students’ statements were read twice, the first time to look at each student’s answers to each of the questions, the second time to identify replies or

themes common across students. The instructors’ responses to each of the questions were read separately, using the same approach as applied to the

students’ statements. The assignment was completed by all the students in four Evaluation of

Intervention classes, each taught by a different instructor. Ninety five students, dispersed over 30 agencies, completed the assignment. One hundred and ninety forms were completed.

Below, we present three sets of findings that emerged from the analyses of the students’ aggregated forms and of the students’ and instructors’ written reflections.

664 R. Savaya

Findings and Discussion

Scope and Clarity of the Documentation

The students filled out forms on 190 client files. Analysis of these forms provided insight into the scope and clarity of the documentation.

Scope

Overall, the analysis showed that certain information was found in all or most of the

files, and other information found much less. The salient features are as follows:

. Client characteristics: over 80% of the files contained data on the clients’ gender, age, place of birth, and physical and mental health. Around 20%, however, contained no documentation of this very basic information. A quarter to a third of the files contained no documentation of clients’ economic or occupational status or of their religion and religiosity.

. Client problems: all the files documented one or more client problem. A quarter to a third of the files, however, contained no documentation of the client’s perception of the problem or of whether or not there had been previous treatment.

. Interventions: over 80% of the files contained data on collaborating professionals or agencies; level of intervention; and main intervention strategies. A quarter to a third of the files, however, contained no documentation of the resources that were invested in the intervention process or on the intervention process itself, such as facilitating or hindering factors and turning points. Some 45% of the files contained no documentation on the rationale for the choice of intervention.

. Outcomes: over 80% of the files contained relevant information on the intervention outcomes. This too is basic information that was not documented in almost a fifth of the files. Most of the files contained most of the information that was queried. This does not mean, however, that the scope of the documentation was satisfactory. The lack of basic information about clients and outcomes in a fifth of the files constitutes a serious omission. So does the absence of documentation in between a quarter and almost half the files on the intervention process and rationale.

Not having such information poses problems on several levels. It makes it difficult

for workers who receive clients from other counselors or agencies to carry out a smooth transfer and to continue the intervention from where it had been left off. It

impairs the ability of both the worker and agency to plan interventions based on learning from previous work with clients. It also raises issues of ethics and

accountability. Without such information, how can one know if clients are receiving the best available intervention?

Clarity

The clarity of the documentation was ascertained from the students’ personal statements. These statements indicated that the quality of the documentation in the

Social Work Education 665

files where it did exist was poor. Many students wrote that the information was

presented in such an unorganized, scattered manner that, to fill out the forms, they had almost literally to hunt for the information, going back and forth among the

pages. They also wrote that they often had to ‘translate’ the information in the file into the categories in the form. For example, in most files, things like ‘intervention

strategies’, ‘intervention outcomes’, and so forth were not labeled, and the students had to figure out these things from what was written. There were also complaints about the

physical appearance of the documentation: some of it was evidently in pencil, which had faded and was almost illegible.

Educational Benefits of the Assignment

Students’ accounts

The students’ personal statements indicate that they learned a variety of lessons from the assignment. Some two thirds of the students wrote, in one way or another, that the assignment augmented their awareness of the importance of ongoing documentation.

Almost half noted their increased understanding of its importance to providing a clear picture of the client’s situation and the intervention process to identifying problems in

the intervention; to critically evaluating, and being able to make changes in, the intervention as it progressed; and/or to practice learning that could be applied to

future work. Almost half were shocked at the poor quality of the documentation they obtained,

noting disorganized reporting and missing information. They realized that if they were to receive clients who had been transferred from other workers or who returned to the agency after a break, they would have very little useful information on which to build.

About half wrote specifically that the assignment had brought them to internalize the importance of documentation. About a third wrote that the assignment helped them

to learn about the agency or its target population. All in all, the students’ personal statements indicate that the assignment fulfilled its

aims, at least in the short term.

Instructors’ accounts

The instructors who taught the Evaluation of Intervention course provided written

feedback, whose overall tenor was that the assignment had helped them to teach the course more effectively. In previous years, they wrote, the issue of documentation had

been covered in one or two class sessions, at a rather abstract level. The students’ intensive work on the documentation in their files made the entire issue of

documentation more tangible and a recurrent and central theme in the course. According to the instructors, the assignment also helped them, the instructors, to

convey, and the students to grasp, the unfamiliar language and concepts of planned

practice and evaluation. In previous years, students were generally put off when the instructors tried to get them to operationalize concepts like problems, aims, outcomes,

666 R. Savaya

intervention strategies, and so forth. They were put off when the instructors spoke of

the importance of precise language, systematic planning, evaluation, and operative definitions. They had viewed these concepts as artificial, imposed, and irrelevant to the

pressured and chaotic environment of the typical social work agency. The assignment, the instructors reported, changed these attitudes. It also narrowed the gap between the

fieldwork and classwork. The instructors’ testimonies highlight the role that social work instruction can play

in enhancing student awareness of the importance of quality documentation to practice, evaluation, and research.

Difficulties of the Assignment

The written accounts that were obtained also revealed difficulties in the assignment for

all the parties involved. Although most of the fieldwork supervisors cooperated willingly with the

assignment, some seemed to be reluctant to expose the poor state of the documentation in their agencies. One said outright that there was no systematic documentation in

her service. Others expressed concern that the assignment would mean more work for them.

For most of the students, the assignment entailed much more work than expected.

They had expected an easy, largely technical transfer of information from the files to the form, and that the students would simply leave blanks where information was

unavailable. Given the scattered, unorganized quality of the information, the students had to invest a great deal of time and energy in hunting for information, ‘translating’

it, and, indeed, figuring out what the documentation said. The assignment made heavier than expected demands on the class instructors. They

had to overcome the reservations of reluctant supervisors. They had to spend a good deal of time, in and out of class, helping students with the difficulties they encountered

in doing the work. And they had to try, as best as they could, to integrate the assignment with the rest of the course curriculum, where no planning or preparation had been made for this.

Recommendations

Several recommendations are in order to alleviate the difficulties that were reported. Before the assignment is given, supervisors should be allowed to raise their concerns

about the exposure and added work that the assignment will bring with the class instructor and consider with the instructor ways of dealing with them. Students

should be told in advance that the assignment will not be easy and a sample file should be reviewed and analyzed in class for practice. Instructors who decide to give the assignment will have to be prepared for the investment of time and energy it will

require of them, and consider how they will integrate it with the rest of the course curriculum.

Social Work Education 667

In addition, I would like to suggest that the assignment can be taken further to lead

the students to consider their practice. The form was designed in such a way that once

the students transfer the desired information to it, they can look at the relationships between client features and problems, on the one hand, and the intervention strategies,

on the other, as well as between each of these components and the outcomes of the intervention (Savaya and Waysman, 2005). Having students examine these

relationships (in a relatively well documented file), instructors can ask them to

consider such matters as the likelihood of the chosen intervention succeeding in view of the clients’ features and problems and, more broadly, guide them to think

systematically and holistically about their practice. Recommendations regarding other issues of documentation are also offered. The

assignment addressed a single narrow aspect of educating social work students to document their work: namely raising awareness of the importance of documentation.

This is a necessary starting point, but not sufficient. Social work students should also be educated in such matters as using computers for case management and

documentation purposes and the problems involved (Reamer, 2005); recognizing and

avoiding distorted or inaccurate documentation and excessive and irrelevant information; and selecting the information to document in keeping with the purposes

of the documentation (Edwards and Reid, 1989; Kagle, 1993; Ames, 2002; Cumming et al., 2007; Foster et al., 2008). In view of the culture of litigation, managing risk in

documentation should also be taught (Gelman, 1992; Reamer, 2005). The students’ statements indicate that the assignment led a good portion of them to

internalize the importance of proper documentation. With this, the assignment’s

ultimate aim was to educate them so that they will continue to document their work regularly and fully when they are full fledged professionals and are not forced to do so

by their instructors and supervisors. How much their heightened awareness will translate into practice in the pressured conditions of their agency work is an empirical

question that requires follow-up study. In view of the international recognition of the importance of quality documentation

to social work practice and the limited attention given to documentation in social

work training programs, social work educators are urged to consider other innovative ways to address the issue.

Note

[1] A copy of the form (in Hebrew) can be obtained from the author.

References

Ames, N. (2002) ‘Social work recording: a new look at an old issue’, Journal of Social Work Education, vol. 35, pp. 227–238.

Bloom, M., Fischer, J. & Orme, J. G. (1995) Evaluating Practice, Allen and Bacon, Needham Heights, MA.

Cumming, S., Fitzpatrick, E., McAuliffe, D., McKain, S., Martin, C. & Tonge, A. (2007) ‘Raising the Titanic: rescuing social work documentation from the sea of ethical risk’, Australian Social Work, vol. 60, pp. 239–257.

668 R. Savaya

Edwards, R. L. & Reid, W. J. (1989) ‘Structured case recording in child welfare: an assessment of social workers’ reactions’, Social Work, vol. 34, pp. 49–52.

Foster, M., Harris, J., Jackson, K. & Glendinning, C. (2008) ‘Practitioners’ documentation of assessment and care planning in social care: the opportunities for organizational learning’, British Journal of Social Work, vol. 38, pp. 546–560.

GAO (2005) Performance Measurement and Evaluation: Definitions and Relationships, (GAO-739SP), General Accounting Office, Washington, DC.

Gelman, S. R. (1992) ‘Risk manageme

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