In This Issue

Ethics Alive!
To Record or Not To Record:
The Ethics of Documentation
by Allan Barsky, J.D., MSW, Ph.D.
Social work documentation. Now,
how exciting is that?! Yes, documentation
is not exactly the most
thrilling aspect of social work practice.
In fact, sometimes the documentation
process can be downright tedious.
Still, if you want excitement in your
professional life, try documenting in an
incompetent, disrespectful, dishonest,
incomplete, or disorganized manner.
Nothing says “malpractice lawsuit”
faster than situations in which social
workers provide direct evidence of substandard
practice in their client records.
Conversely, good old boring records
are vital to risk management, reducing
the risk of malpractice lawsuits, professional
disciplinary hearings, and agency
discipline.
Standard 3.04 of the National Association
of Social Workers (NASW) Code
of Ethics (2008) provides social workers
with guidance about documentation
and record keeping. Part (a) states that
social workers should ensure their
documentation is “accurate and reflects
the services provided.” That makes
sense. Be honest. End of sentence.
Part (b) instructs social workers
to include sufficient information to
“facilitate delivery of services and to
ensure continuity of services provided
to clients.” Once again, this standard
seems obvious. Records are supposed
to support the provision of services.
Social workers, supervisors, and colleagues
need to know about the client’s
concerns, the client’s goals, and the
plans for reaching those goals. Good
records can keep the helping professionals
and clients on track, and ensure
that services are provided in a competent
and effective manner. For these
purposes, comprehensive, and perhaps
expansive record keeping might be suggested.
Isn’t it better to have more than
enough information, rather than not
enough?
Part (c), however, suggests that
“social workers’ documentation should
protect clients’ privacy to the extent
that is possible and appropriate and
should include only information that
is directly relevant to the delivery of
services.” Ah, there’s the rub. More is
not always better. Given that clients
have a right to privacy, documentation
should be limited to what is relevant
to service delivery. Even though most
client records are “confidential,” there
are many people within the agency and
beyond who could have access to all or
parts of the records:
• Supervisors and co-workers
• Researchers and program evaluators
• Government auditors or other officials
responsible for monitoring
and accountability
• Insurance providers
• Other agencies or people as authorized
by client consent
In addition, client records may be
used in courts under various circumstances—for
instance, in child protection
cases, in family law cases, in malpractice
lawsuits, and in mental health hearings.
To protect client privacy, social
workers should consider limiting what
they document, so as not to embarrass
clients or share information that clients
may want to remain private.
“So,” you may be asking, “how do
I balance the need to provide full and
accurate information in client records
with the interest of protecting client
confidentiality?” I’m glad you’ve asked.
To address this balancing act, consider
the following factors: laws, agency policies,
client wishes, and social worker
needs.
First, various statutes and regulations
may govern your practice,
including what information needs to be
recorded, how records should be maintained,
client rights to access records,
and under what circumstances confidential
records may be shared with
others. At a federal level, consider the
Health Insurance Portability and Accountability
Act (for health settings) and
Federal Education Rights and Privacy
Act (for educational settings). At a state
level, there are specific laws regulating
child protection, criminal justice, mental
health, and other practice settings.
At a minimum, records should meet
these standards. For instance, when
requesting reimbursement for services
provided under Medicaid, consult the
laws governing Medicaid.
In addition to laws, agency policies
also govern what type of information
needs to be gathered—for instance,
date of contact, purpose of meeting,
client concerns, and information
related to safety (child or elder abuse
and neglect, suicidal or homicidal
ideation, drug use, or intimate partner
abuse). Note that when laws and
agency policies conflict, laws generally
take precedence. For example, an
agency policy may require gathering
client Social Security numbers, while
a state law may prohibit this. Follow
the law—and change agency policy to
comply. Agencies often provide specific
forms (digitally or on paper) requiring
social workers to gather and document
particular information as part of their
intake, assessment, intervention, and
evaluation processes. Although it is
important to follow the law and agency
policies, these are far from the only
considerations.
Standard 1.02 of the NASW Code
reminds us that clients have a right to
self-determination. Ideally, this right includes
the ability to provide input into
what types of information are gathered
and documented by the social worker.
Consider a client who is having extramarital
relations, but does not want this
information documented. Alternatively,
consider a client from another country
who does not want you to document
that she is working without a proper
visa. Does the law require you to document
this information? Does agency
4 The New Social Worker Winter 2017