Effective Date: 5-1-19
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 ensure the safety of children must be guided by a precise recognition of the safety concerns, as well as the strengths of the family, the ongoing narrative should focus on clear, behavioral definitions of the current concerns 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 documentation must describe strategies for improving the caregiver’s ability to keep the child safe.
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. 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 participation in treatment and intervention and record only information that is essential to an understanding of the family system and its ability to provide child safety.
Treatment-focused summarized recording is useful to describe ongoing trends, progress, or regression, within a certain time period. 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 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 lengthy documentation
- Describe people in a few words with clarity. Noting the relationship and roles of individuals to others in the case is important
- Avoid repetition. Even when there is a change of Children’s Service Workers, there is no need for repeating information already in the record
- Pay particular attention to items that may be critical in court testimony.
All Children’s Service Workers and supervisors will use FACES and Document Imaging as their primary form of documentation. Handwritten notes should be destroyed after they have been entered in FACES in most instances. This also includes any electronic notes such as those contained on electronic devices. Any information maintained is subject to subpoena.
The record aids the Children’s Service Worker in planning for and conducting their work. In addition, it provides valuable information to staff who may be subsequently assigned to provide services to the family. Thorough FACES contacts will also demonstrate compliance with agency policy and legal mandates.
A client also has a right to insert a statement into his/her case record. A client includes a person for whom a record exists, including the parent of the children in the treatment case. Division staff shall document the date the statement is entered into the record and may provide a response to the inserted statement, but must inform the subject of the record/author of the statement of the Division’s response and give the subject opportunity to review it.