Tips for social workers on case recording and record keeping

How to write clear, jargon-free, accurate records that can be read by service users

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In a Community Care Inform Children’s guide, David Wilkins, senior research fellow at the Tilda Goldberg Centre, University of Bedfordshire, gives practical advice on case recording and record keeping. Inform Children subscribers can read the full guide, which includes interactive exercises. Here, we present a few key tips from the guide.

Ask social workers what they dislike about their job, and ‘too much paperwork’ will likely be high up the list. Recording cases and filling out forms can feel an unnecessary layer of bureaucracy, taking time away from seeing service users.

Be this as it may, keeping accurate, up-to-date records is a key social work task. What is recorded in files can have a huge impact on what happens to service users. It can give children in care information about their family they otherwise might not have. And, quite simply, it matters to the people who use social work services.

Write clearly and without jargon

It is too easy in social work to unwittingly use complicated language or jargon in a way that obscures what you mean. When under pressure, many social workers use abbreviations to save time – POVA, ICPC, CP and so on.

One of the problems with jargon is that sometimes professionals use it without even realising because it becomes part of their everyday vocabulary. Phrases that you may not consider as jargon can still be confusing for service users. And even without jargon, social work records can still be too complicated and lacking in clarity.

Using more common words does not mean being patronising or missing out important information. But a key test of how well you understand something is being able to explain it to someone else.

Distinguish between facts and opinions

Social workers need to be comfortable making – and recording – professional judgments. Being personally non-judgmental is important but being able to judge levels of risk and need is a key social work skill.

The inclusion of opinions in social work records is not inherently problematic. Good records will contain both facts and opinions but there should be a clear distinction between the two. Otherwise, it becomes all too easy to mistake opinion for fact and to leave opinions unsubstantiated.

Record the wishes, feelings and views of service users

In many serious case reviews, it is found that the children’s views and needs were lost among discussion of the parents’ views and needs. This is not a new problem. In his landmark 2003 report regarding the death of Victoria Climbié, Lord Laming noted that Victoria’s wishes and feelings were almost entirely absent from her own file. This may also be the case for adults, where the service user has additional communication needs, severe mental health difficulties or learning disabilities.

Before you can record the wishes, feelings and views of service users, you first need to know what they are. This can only be achieved through spending time with children and adult service users and forming a trusting and meaningful professional relationship.

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2 Responses to Tips for social workers on case recording and record keeping

  1. ann June 8, 2017 at 11:31 am #

    This is a good article and I would like to add the need to make defensible decisions. So keeping jargon at a minimum is key, but also recording your options and the reason for the decision made.
    Defensible decision-making

    Defensible decision-making is defined by Professor Hazel Kemshall in a report, ‘strengthening multi agency public protection arrangements’. It is imperative that practitioners make defensible decisions in all cases. This is a cut and paste from her report (available on line) but it does not just apply to managing offenders, it applies to all matters in terms of working with family, investigating crime etc. So defensible decision making includes (with a couple of additions that i have made to the list):-

    ensure decisions are grounded in evidence;
    use reliable risk assessment tools;
    collect, verify and thoroughly evaluate information;
    record and account for decision-making;
    communicate with relevant others and seek relevant information you do not have;
    work within agency policies and procedures;
    use your Professional judgment
    Hear the voice of the child
    match risk management interventions to risk factors;

    This will ensure that decisions can be evidenced, and defended, if necessary, and can demonstrate that at that moment in time with the information available at the time i have these options available and this option was taken because…………………………

  2. Blair McPherson June 15, 2017 at 10:31 am #

    Is “assessment” a jargon word ? I agree with the statement that proffessionals use some words and phrases so often that they don’t recognise them as jargon.