1.4.4 Treatment-Focused Summarized Recording

A vast collection of information, unless required for legal purposes, tends to inhibit an accurate reflection of treatment. It requires others to weigh and interpret information in order to glean important facts. Treatment-focused summarized recording, on the other hand, reduces the amount of peripheral information in order to focus staff on the family’s progress and treatment.

Since the Children’s Service Worker’s efforts to improve family functioning must be guided by a precise recognition of the presenting problems and specific unacceptable behaviors to be modified, as well as the strengths of the family, the ongoing narrative should focus on clear, behavioral definitions of the current problems to be addressed. Focusing on specific behaviors is essential if the worker is to respond appropriately to the family system’s evolving character, needs and priorities. The narrative must describe strategies for resolving these problems.

As no record can accurately reproduce everything that is said and done, the Children’s Service Worker must sift out and select items of information which he/she thinks are of the greatest significance. Generally, the narrative should not include all that happened during any one interview, conference, or time period. Treatment-focused summarized recording briefly describes what took place between the worker and family or collateral. It should summarize events based upon the worker’s evaluation of their significance to the treatment process.

Omit excess material and communicate only the important activities and events relating to the treatment process. Carefully appraise the facts pertaining to the reasons for Division involvement with the family and the family’s reactions to treatment and intervention and record only information that is essential to an understanding of the family system and its dysfunction.

Treatment-focused summarized recording is useful to describe ongoing trends, progress, or regression, within a certain time period (i.e., 30 days). Topical headings may be used to further organize the content of events, which occurred within the time period.

The following guidelines will assist in the preparation of treatment-focused summarized recording. The Children’s Service Worker should:

  • Keep complete and accurate notes by date in a notebook/pad so meaningful material can be selected for the record
  • Evaluate and organize the material before recording it. Identify items that pertain to the treatment process
  • Omit unnecessary and repetitious words
  • Avoid lengthy explanations or detailed accounts of activities that do not focus on the treatment process. Activities such as searching for a record or attempting to reach someone by phone do not require much attention
  • Describe people in a few words with clarity. Recognizing the significance of their appearance and behavior is important. Lengthy description of an individual for the sake of description is not purposeful
  • Avoid repetition. Even when there is a change of Children’s Service Workers, there is no need for repeating information already in the record and
  • Pay particular attention to items that may be critical in court testimony.

Case Transfer Summary – In the event a child or family moves from the county of jurisdiction, a transfer summary must be completed within 10 days by the worker in the case managing county prior to transfer of case record. The transfer summary should include:

  • Reason for opening and reason for transfer
  • Current status of child and family with regard to established goals
  • List of upcoming appointments as well as with whom they are scheduled (e.g. upcoming FST meetings, medical appointments, court dates etc.)
  • Visitation plan if applicable
  • Any other information pertinent to the case that is necessary for optimal service delivery to the family.

Transfer Summary Example

On 2/24/2014 a case was opened as a result of a substantiated report of educational neglect and substandard living conditions in the home. On 4/1/2014 the entire family is moving to an adjoining county where they have procured housing closer to Mr. Jones’s place of employment. Family will continue with parent aide services on a weekly basis to assist them towards goal of learning appropriate housekeeping skills. Billy Jones will continue with IEP in his new school in order to achieve his goal of advancing to the next grade level. Billy has an appointment on 3/15/2014 with Dr. Jones (573-999-6666) for a psychological evaluation.

The transfer summary should be submitted to the immediate supervisor for review and approval in FACES.

Closing Summary – This summary is done within thirty (30) days of terminating services with a family. The closing summary should include:

  • Reason for opening
  • Current status of child and family including safety status of child
  • Justification for case closure which should include behaviorally specific description of how the family has stabilized and achieved the goals in the original or updated case plan
  • Family reaction to termination of services
  • Community referrals made by worker to support family after case closure
  • Any ongoing aftercare services the family will be receiving (e.g., continued counseling). (Reference the Risk Reassessment, CS-16E, and the Termination of Services After Care Plan, CD-14D)
  • For all youth exiting care to independence, an identified plan for self-sufficiency which addresses the nine domains of independent living and an exit verification letter stating the dates the youth was in care. Documentation of when the Exit Packet and the Exit Verification letter were provided to the youth is included in the narrative.

The closing summary should be submitted to the immediate supervisor for review and approval in FACES.

Chapter Memoranda History: (prior to 1/31/07)

Memoranda History: