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The Information Guidance for Social Work Assessment Form Sample Word Document

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A Complete Manual with respect toSocial Work Assessment Form Sample Word Document

welcome everyone to our education.session this afternoon.my name is mrs. Sheppard Decker and I'm.a social worker with the doctor you to.me health center in bought wood and a.member of the NASW Ethics Committee I.have the honor of being the moderator.for today's education event social work.documentation standards this is a topic.that is of great interest to social.workers and we have over a hundred and.eighty-two social workers from across.the province tuning in today this.webinar was a collaboration between the.Newfoundland and Labrador Association of.Social Workers and the Canadian.Association of Social Workers the.presentation was developed by the NASW.ethics committee the webinar.presentation will be approximately 45.minutes followed by a 15-minute.question-and-answer period that I will.moderate please send in your questions.throughout the presentation only myself.and the presenters will see the question.all the housekeeping details you need.like how to access the recording where.to download the slides and how to get.your certificate of attendance are all.included in the housekeeping widget that.popped up when you first logged on.members attending this session can claim.one required CPE credit as for the NASW.CBE policy under the workshop category I.now want to introduce our speakers.Annette Johns and Genevieve Corbin.excuse me and if John is a registered.social worker and the associate director.of policy and practice with the NASW.she began employment with panelist w in.2004 after working several years in.Community Social Work she holds a.Bachelor of Social Work and a Masters of.Social Work from Memorial University of.Newfoundland her professional interests.lie in social work ethics social policy.analysis and Social Work regulation and.that is the staff liaison with the.Ethics Committee.Genevieve Corvin is also a registered.social worker following more than 35.years of Social Work practice.Genevieve retired in 2016 Genevieve has.held positions in both administration as.well as clinical practice she has worked.across multiple fields of practice.including Child Youth and Family.Services mental health and addictions.quality and risk Genevieve was a.surveyor with accreditation Canada and.International for 16 years as a surveyor.and team leader she coached both.government and non-government.organization in the developments.promotion implementation and evaluation.of administrative and clinical ethical.framework since retiring Genevieve has.traveled extensively throughout Asia.where she has taught worked as a.volunteer in the service of children and.pursued cultural experiences which.encourage reflection and the application.of holistic practices so without further.ado I will now pass things over to.Annette and Genevieve to begin.presentation thank you so much Missa.it's a net Jon's starting first so.myself and Genevieve are both going to.be presenting the material this.afternoon so we'll pass the phone back.and forth so I just want to say a.sincere welcome to everyone and we're so.excited to be here this afternoon for.this webinar social work documentation.is certainly something that social.workers are interested in and we hope.that you find the webinar today to be.useful to you in terms of your thinking.about your documentation practices the.purpose of today's session really is to.discuss documentation and social.practice as it relates to ethics.professionalism and accountability and.to highlight and review the NASW.standards of practice for social workers.in Newfoundland and Labrador.particularly as it relates to.documentation and recording and it's.important to note that these standards.do incorporate the NASW standards for.Social Work recording that were released.in 2014 so just a little bit of.background on the standards of practice.this document these standards were.approved by the Board of Directors on.February 2nd 2018 and were adopted into.bylaws I'm a fort 2018 so we've had them.now for about a year and the process.that we use in developing the standards.was quite comprehensive.we did a jurisdictional review we do.review of best practice standards we.engage members in consultation.throughout the process and also we.obtained review and feedback from.members on the draft document before.they were approved so these standards.really outline the practice.acquirements for social workers in the.province to ensure safe ethical and.competent professional practice there.are 24 standards contained in the.document and there is overlap between.the standards and these standards are.applicable to all fields of Social Work.practice so now in addition to the Code.of Ethics and the guidelines for ethical.practice produced by the Canadian.Association of Social Workers we must.also know and understand how the.standards of practice apply to us in our.practice so the NLA SW has developed.several guideline documents which are.integrated into the standards of.practice to highlight best practices and.support social workers in their practice.and these documents include the.standards for cultural competence and.social practice Spanish for technology.use in social practice standards for.supervision and standards for child.custody and access assessments and of.course the 2014 standards for Social.Work recordings which is what we're.going to be focusing on today.so historically most professionals.consider the record as a tool for their.own use.now we record for the clients other team.members and our employing organisations.information is owned by the client the.medium is owned by the organisation and.the professional is the guardian of the.information the during social works.early years social workers view.documentation primarily as a mechanism.to facilitate Theory building research.and teaching the Social Work record.today now serves primarily to facilitate.service delivery records of.interventions with clients and services.provided is important in terms of.accountability to the client.organization and from a legal.perspective and as noted in the 2014.standards for Social Work recordings the.purpose of Social Work recording is to.provide a clear statement of the Social.Work assessment intervention and.decision making professional.accountability and transparency to the.client an organisation in keeping with.relevant legislation an opportunity for.critical thought and reflection on.professional practice and service.delivery relevant information to.facilitate service delivery continuity.of care and termination of services.information for the purposes of.supervision documentation for the.purposes of research and program.evaluation risk management and quality.issuance and as a record to facilitate.interdisciplinary communication and.collaboration if we do not documents.there will be no evidence of our.involvement with our clients or if the.work that we've done and legal experts.would tell us and if it isn't written it.wasn't done as patty Erving who worked.as a social worker in Newfoundland a.mentor for many years used to say Social.Work documentation is your written.reputation and I always remember her.saying ash so the quote that's up on.your screen there now is from Wilson and.a cited in a book written by Nancy.siddell on social work documentation.which is included in the reference list.at the end of the presentation and it.talks about recording not being and not.being an isolated part of social.practice but that effective recording.goes hand-in-hand with effective.interviewing and casework and it's.impossible and undesirable to discuss.one without the other and this quote.certainly speaks the importance of.documentation and practice well we may.see it as an administrative test that.muskets must get done documentation is.really part of the entire service.delivery documentation keeps us focused.on the work and allows us to reflect on.what may be working well or maybe what's.not working well are we meeting the.client needs.does the Service need to change does the.record and reflect professional decision.making if you left the position tomorrow.put another social worker or.professional pick up the fall where.you're left off and continue the service.without documentation it would be nearly.impossible to remember all the important.details in events that happen in one's.clinical work and this in turn can.impact on client care so social.recording we know is an integral and.essential component of Social Work.practice and if we explore the.components of ethical practice we can.clearly position social recording into.our ethical framework so first.sample if we look at context we do have.relevant laws and workplace policies.that guide our documentation for example.some organizations have clear policies.on when documentation must be completed.and if we look at the social worker we.do have our code of ethics and our.professional standards that speak to the.need for high quality Social Work.documentation in the best interest of.clients and every practice document I've.read documentation and recording are.included and highlighted as a important.professional and ethical.responsibilities and then we have our.client fines have a right to know how.their personal information is being.recorded for what purpose and how their.information will be protected they also.have a right to access information about.what is written about them and to.correct any any inaccurate information.and this is where some or any.organization have policies in place that.will address how clients are able to.access their records and finally human.rights so we know clients have a right.to privacy and ensure the accuracy of.information that's being recorded about.them and as social workers we safeguard.client privacy while ensuring clients.receive the highest quality service as.possible so you can see here how.documentation is such an essential.component of ethical practice so we're.now going to get you to do a poll for us.because we do well we know that.documentation is important we also know.that there it's an area that can cause a.lot of frustration as well so the poll.we want you to engage in with us right.now is what you see as a number one.systemic barrier to effective.documentation is a high caseloads.competing work demands challenging work.environments lack of clear policy or.limited access to consultation and if we.polled social workers at any point in.time and asked what practice activity.they would rate at least interesting or.burdensome many if not most would say.recording but yet it's always the topic.that there's a high a lot of interest in.from social workers I think so.now review the results so we do have.competing work demands came up as number.one in terms of the number one systemic.barrier at 65.1% followed by high.caseloads at twenty almost twenty eight.percent only four point seven say a.challenging work environment or and two.point three limited access to.consultation and zero percent said lack.of clear policy so it's obvious that.there's lots of group policies out there.but sometimes the competing work demands.are impacting on our documentation.practices so that's very interesting.thanks for thanks for doing that.rebel back and so in terms of practice.resources that in LA is w has developed.in 2016 we do produce the practice.matters on the topic of documentation.and we did look at why some of the.systemic barriers were and what social.workers and organizations can do in.terms of trying to address some of those.systemic barriers so that document can.be found on our website under our.practice resources section but we did.highlight issues such as developing.policies that work for the client and.the social worker but we know here.there's lots of great policies that are.out there offering and tending training.sessions on topics including braiding.using documentation audits as an.educational opportunity and that's.really a really good strategy.developing strategies to address.workload issues and using forms for.examples such as our professional.special practice council a staff or team.meeting to really discuss and focus on.documentation and of course ensuring.access to supervision so in addition in.addition to reflecting on the systemic.barriers I'm working to develop.strategies to address these barriers and.it's important to social workers.understand and are familiar with.professional standards for social work.documentation and engage in.opportunities to reflect on their own.documentation practices and so we're not.going to review those those standards.and.and highlight some tools and resources.that social workers can use for.self-reflection so um there are many.different types of recording and the.manner in which one records may depend.on factors such as agency requirements.our own theoretical orientation and a.type of intervention that's being.provided and the nature of the.intervention generally guides the format.and content of the record and how the.information is shared so as I noted.previously we did update the standard.start work recording in 2014 and that.document outlined at eight standards.that guide recording at occupation and.social practice which again have been.integrated into the 2018 standards of.practice for social workers so as social.workers it is our responsibility to.document ethically and competently we.ensure that our records and.record-keeping practices and keeping.with the values of the profession that.speak to respect integrity.confidentiality and competence our.records must be timely and accurate and.let it all and should be contained in.one fall with the record being an.electronic paper or both Social Work.documentation should only include.information that addresses the client's.needs and meets legislative ethical and.organizational requirements information.that's not relevant to the service.delivery does not need to be maintained.again this gets back to the Human Rights.peace in the components of ethical.practice and the clients right to.privacy as part of the informed consent.process social workers and form clients.about their record-keeping practices how.they can access their records and.keeping the policy and legislation and.how information may be shared within a.team environment for example it's.important to document that the document.is informed consent before the service.delivery is is initiated documentation.of point consent being coming who in a.written record or in written form in a.case note or both however it's important.to highlight that.a standard administrative informed.consent form signed by a client may not.necessarily constitute informed consent.when engaging client and informed.consent it's really important to view it.as a dialogue between the social worker.and the client and as a decision making.process where the clients get to make.decisions based on discussion and.information and this should be happening.at the beginning of the relationship and.throughout the relationship is necessary.other areas that will be covered as part.of the informed consent include the.nature of the service being provided.limitations to confidentiality the.potential risks and benefits of proposed.intervention options that are available.the right to seek a second opinion or.refuse or even see services and how.termination of the professional.relationship will be handled so for.example how long will the proposed.intervention take as this sets.expectations and parameters upfront so.all this information should be presented.in a way that is easily understood by.the client and is culturally appropriate.but getting back to the clinical record.the record itself should contain enough.detail and be organized so that a reader.can understand why particular approach.was used and to allow another person to.continue the care should the social.worker not be able to do so for example.a change in employment or retirement etc.incorrect records may lead to.ineffective assessments and services.error errors in professional.decision-making and planning and.unsatisfactory client outcomes one's.decision-making must be consistent with.the record and what has been documented.documented otherwise decisions can be.challenged recordings therefore should.be completed following the intervention.as soon as reasonably possible.thereafter as noted innocence of.practice the need to document more.immediately may depend on the complexity.of the case degree of risk impact on.service delivery and/or any legislative.requirements that might pertain the.longer the delay in recording the.greater the likelihood that the record.could be challenged so.workers should also include their name.and professional designation incline.notes and it's so because it is.important that the author of the note.can be easily identified the Social Work.record should contain all information.that is clinically relevant and.significant to the service delivery what.do people need to know someone should be.able to pick up your record have a clear.sense of what you saw and heard and the.rationale for any decisions that you.made to allow for continuity of care.it's always best to assume that your.client and others are going to be.reviewing your records so it's always.good to write as if you're expecting an.audience to your Social Work recording.at a minimum as you can see from the.slide Social Work record should contain.the clients name contact information why.they're there the presenting issue what.they're requesting the informed consent.which I went through previously copies.of any relevant documents referral those.kinds of things should reflect the.professional assessment goals.intervention outcomes and any progress.notes in chronological order should also.be in the Social Work record in terms of.electronic communication it's important.to to look at that in terms of if it's.of clinical significance or any.electronic client communication for.example an email that you feel is.clinically significant or relevant to.the service that will be documented as.well any communication with other.professionals or contacts including.consultation those kinds of things.importantly it's also important to.include a clear statement of when and.why the professional relationship is.terminated so it's always good to have a.summary no there are when when them when.the relationship ended and for private.practice any fee for service agreements.as well so now I'm going to pass things.over to DJ Neffe to continue the.presentation Thank You Annette so we're.going to continue on speaking about the.documentation standards.and so the literature provides an.extensive overview of what's considered.a good clinical record.so documentation as we've been saying.allows us to maintain a record of our.clinical assessment this would have your.initial information name and contact.information for the client reason for.referral client perception of the.problem we would also have a description.of the client brief personal history.relevant relationship social and.cultural factors what the current.situation is the stressors the supports.the strengths and limitations we would.also have the formulation what is the.social workers opinion based on a.summary of the perpetuating and.protective factors and a plan to include.the clients wishes schools for treatment.a tentative agreement we would have.clinical interventions progress notes.what's relevant in the clients life.summary of the interventions contact.with cloud collaterals consent for.releases information all of this and.more client progress and outcomes must.also be clearly documented termination.would be documented closing notes what.is the evaluation of services what.referrals were necessary what are the.plans for follow-up when recording all.professional opinions need to be.supported with facts it's important that.those reading the file will also be able.to make this distinction for example.let's look at the statement client has.poor coping abilities well what does.this mean is this a general statement is.this accurate in all situations what is.the context for this how is it displayed.these are the factual points which will.need to be addressed and done to support.this pre occasion that a client exhibits.poor coping abilities and in what.situations professional observations.must also be distinguished from.information provided directly by the.client with the record reflecting.professional decision-making.incomplete or inaccurate records can.lead to inadequate services for the.client and we always have to keep that.front and center and everything that we.write in addition any significant.financial issues such as risk of harm to.self or others and the relevant.assessment and measures taken to ensure.safety must be documented the reason for.any decision to breach confidentiality.should be clearly noted and the very.significant point social workers should.also document their ethical decision.making processes and decisions so the.NLA SW ethics committee has released the.fifth edition of the ethical compass.which addresses this issue hopefully.you've had a chance to read it but if.not you can access it on the NASW.website under practice resources the.protection of client confidentiality and.the clients right to privacy as it.relates to record-keeping is also very.important as noted in the standards of.practice social workers disclose client.information to others with the.documented informed consent from the.client social workers may disclose.client information without client.consent when such disclosure is.necessary to prevent serious imminent or.foreseeable harm to self or others in.this situation social workers use their.professional judgment to determine how.much client information needs to be.discussed to prevent harm and if what.information is shared with clients in.advance of that disclosure social.workers may also disclose client.information without consent when.required by law or court order the CA SW.guideline for ethical practice states.that where the consent of clients is not.required.social workers attempt to notify clients.that such access has been granted if.such notification does not involve a.risk.to others when disclosure of Social Work.records is required by a court order or.subpoenas.social workers should be familiar with.the nature of the requests they should.seek consultation take care not to.release more information than is.required inform the client where.appropriate and strive to protect plain.confidential information from reasons of.unreasonable public exposure so this.latter point may involve applying to the.courts that some client information be.withheld from the public record however.it is recommended that consultation with.the supervisor and manager would be.prudent in this situation so where you.have is these levels of complexity then.you would want to seek out that.consultation in relation to the.retention of client files unless an.organizational policy exists the NLA SW.recommends that client records be kept.for a minimum of seven to ten years from.the date of the last entries about seven.to ten years from the date of the last.entry however where their client is.under the age of 18 when the last entry.was made the client file should be kept.for a minimum of seven to ten years.after the date that the client turns or.would turn 18 so when we continue on and.we will look now to the electronic.record and and some some those social.workers take precautions to ensure and.maintain the confidentiality of.information transmitted to other parties.through any form of electronic.communication social workers should be.aware of and inform clients of the.limits of confidentiality that may apply.to these forms of communication as noted.in the nla SW standards for technology.used in social relaxants 2012 the.following are some of the areas that you.you would want to consider though email.phone and text messages from clients.that have a clinical or therapeutic.significance should be documented in the.client file when electric modes of.communication are.use in practice is important that social.workers include policies around.documentation of electronic.communications within the informed.consent process I was outlined in the CA.SW guidelines for ethical practice 2005.social workers protect the.confidentiality of clients written and.electronic records that's on page 8 when.using electronic forms of documentation.or information collection for example.laptops it's important that social.workers have good risk management.strategies in place for example an.example that would be the appropriate.passwords that appropriate storage of.the information when social workers.communicate with clients via email or.tax social workers discuss with clients.the type of information appropriate for.email text in keeping with.organizational policies the Code of.Ethics and best practice guidelines this.information should as well be clearly.documented in the file that the.discussion has been had and what you've.been talking about the wind' team.members or care providers communicate by.email or electronic technology which is.more and more common reasonable efforts.must be made to ensure the protection of.client privacy and confidentiality and.risk management strategies must persuade.clients should be informed about this.method of team communication and.documented in the client file as part of.form consent process so a few weeks ago.the NASW hosted a webinar on personal.health information act that highlighted.issues pertaining to the collection use.and disclosure of personal health.information and practices for protecting.client information so you can access.this recording on the NLA SW website.last but not least the last standard.pertains to professional development so.as a part of the ongoing professional.development social workers continue to.assess their knowledge of Social Work.documentation through self-reflection.and consultation with peers and managers.and supervisors and engage in personal.development opportunities to continue.their learning into to strengthen their.competencies so to assist with one's.reflection on professional development.needs and iOS W has developed a.self-reflection questionnaire that you.might find useful periodically it could.be helpful if you to reflect on the.questions and engage in collaborative.dialogue with your social work peers so.you know for example if you're.reflecting on where you are in terms of.your your documentation skills and and.your development needs.you could ask you some how do I view.documentation in my practice what do I.see as the primary purpose for social.work documentation does this have an.impact on how I document.I'll familiar MI with the professional.standards for documentation how would I.describe the link between assessment and.documenting how do I make decisions and.want to include in my documentation what.are my documentation strengths what is.it that I do well what is it that I.don't do as well how would I describe my.writing skills what areas do I need to.improve on in my documentation how can I.further my skills and competencies and.documents what gets in the way of my.documentation and recording what.strategies might be helpful in.addressing these barriers these are all.very very good questions - - for self.reflection or reflection with a peer or.colleague so we want now to ask you to.take part in another poll so Vienna lis.W Ethics Committee produced a.self-assessment - on documentation and.informed consent in 2017 so we are.interested to know from you how familiar.are you with this document so do you use.it frequently.do you know that it exists but haven't.used it or have you never heard of it.you could take a few minutes and just.let us know where you are with that.Thanks so we'll just take a few minutes.to see the results there so you can.switch that's an interesting that's very.interesting so 50% know it exists but.have not used it yet and 50% have never.heard of it so we're going to be talking.about that now for the next few slides.so it's very timely this webinar is very.very timely those results are quite sick.so the guideline document so this is a.really good tool I think that you may.find you'll find it useful so self.assessment tool for informed consent and.documentation the disc document provides.a checklist that social workers can use.to reflect on and evaluate their own.practice pertaining to inform consent.and documentation and identify areas for.continuing professional education the.checklist while it's not intended to be.included in your Social Work record it.can be used for discussion with peers.with managers and supervisors to.identify best practices or provide the.basis for documentation audits so the.material can be used by social workers.when providing field instructions to.Social Work students to foster an.understanding of best practices and.informed consents and social work.documentation so it has multiple uses.more than one so important important.resource as a reflection tool it can.help you identify issues that you may.need to address in your documentation or.areas that you may need to incorporate.into your informed consent process so.what it is is it's a tool to to see.where you are in your documentation what.your strengths are and where you might.want to.zooom or development or more more.dialogue with your with your peers so.we're going to look inside the tool for.for a little bit so we have an example.here some of the elements for.documentation that's highlighted in the.documents as a self-reflection exercise.you can use this to assess if you cover.these various areas you can start cover.them consistently inconsistently or are.they just not applicable to your work.for example as an example do you.consistently document written and oral.informed consent so we have just had.several slides that tell us how very.critical and that is both ethically and.legally and otherwise so this would ask.you are you doing that consistently.inconsistently do you consistently.include clear description of the.presenting issue and description of the.professional services requested again.something that we have seen through a.number of slides the document also.contains the piece pertaining to private.practice so if you're in private.practice do you clearly document the fee.for service agreement in the client.record consistently or inconsistently do.you clearly articulate your policy on.the collection use and disclosure of.personal health information very very.very very important question connected.to documentation is of course informed.consent so the document also explores.the elements of informed consent that.are important to service delivery this.is I think as you as you explore this.resource more carefully and on site that.you'll see that is a wonderful resource.for social workers to use in their.practice and you can find this document.on the NLA SW website WWN LA sWCA so.I'll just say that again.wala sWCA so we have another full and.so what we're curious to know a little.bit more about from you is would you is.this statement true or false.is it true that more information in a.client note is always better or is or do.you think that that's false so again.we'll take a few minutes see that.okay so now I see 3.5% of you think that.that is false and 6.5 percent is that.okay.so it's bearings to mine how do we know.when you're documenting too much or too.little documenting too little might.contribute to omitting relevant and.important facts assessments and.activities that contribute to providing.the best possible service for a client.on the other hand over documentation.leads to decreased efficiency its.effects client privacy and it can.increase liability so as social workers.were educated to think about the person.in the context of their environment and.we have a systemic view this makes it.difficult because we consider large.volumes of information but what we don't.need to record we don't need to record.large volumes of information however.there's no set standard on how lengthy.or how brief your case recording should.be however it's important to be concise.while still including all information.the depth of the recording and analysis.depends upon the objectives of the work.the higher the risk the more complex the.situation higher legal liability than.more details the recording so when.you're looking to the context that.you're working within will in its own.way help you determine what needs to be.recorded and what doesn't need to be.recorded so when you're looking at how.information how much information to.record what we need to consider is what.is the relevant information what is.relevant to that situation as noted.earlier only relevant information.pertaining to the clients needs and the.delivery of services needs to be.documented in the Social Work record so.a helpful question to keep in.when documenting is why am i recording.this information this reflection will.help tease out information that while is.interesting would be of no benefit to.have in the records the type of.information considered relevant will.depend on the context of practice and.professional judgment of the social.worker including what we have already.talked about in terms of risks and legal.liability and so on and so forth the.records should be complete so to use the.words of Robert Solomon a lawyer in.Ontario who works closely with the.Social Work profession the record should.reflect your honest and best view of the.client circumstances he says call them.as you see them to the best of your.ability the record should reflect your.reasonable breast view driving force.should be the clients need is the.information relevant to treatment or.services that I am providing is this.information necessary to support ongoing.quality of care those would be the.reflective questions you can ask as you.document professional judgment a.practitioners decision must be.consistent with the record upon which is.based if not the decision can be.challenged and the practitioner may be.accused of being arbitrary or.discriminatory the statements of opinion.must be stated as an opinion and clearly.distinguished from facts professional.opinions must be based on the facts and.consistent with one's education a.clarity and language so it's important.that the file not be left open to.misinterpretation the writing and the.language needs to be clear one of an.example for example writing with clarity.is avoiding the use of ambiguous.abbreviations or acronyms for example.the abbreviation sa that could like.read that as meaning substance-abuse.another social worker could pick that up.and think that it is indicative of.sexual assault those are two very very.different issues and you would not want.them confused timing is everything and I.know that we're also clear about the.timing information should be recorded.when the intervention or the event.occurs the record can be challenged as.being inaccurate or not a true.reflection of the facts when in fact the.timing is not it's not accurate so in.some cases where the court requests to.file request the file the judge could.deem the record as inadmissible because.there's been too long a gap between the.client contact and when that information.was recorded so timing is critical I.mean it's critical to you know it has to.be as close to to that interaction with.the client as possible.as possible to do another tip you know.another tip to to use to be cautious it.is the whole area of jot notes so not.notes are typical typically used to jog.one's memories and when writing a case.zone however is recommended that jot.notes not being maintained.once the note is written in a client.file jot notes can be subpoenaed to.court as part of the Social Work record.for example and client privacy can also.be impacted through through jot notes so.I'm going to pass this over the phone.over to Annette again and she's going to.go through a case scenario Thank You.Jennifer so we do have a short case.scenario it's hard to do this by webinar.but we we want to have one in there just.to kind of get get some context around.some of the material that we've been.presenting so this is a case of Jane.who's a 25 year old female who presented.to a drop-in Medical Health Center for.the first time she was in the middle of.University exams.feeling quite anxious and overwhelmed.money was tight and she fears that she.won't do well on her exams and will end.up disappointing her family she's.studying chemistry in a workload has.been particularly high in this semester.and before switching to chemistry she.was doing sociology someone asked gee.Noah that she does experience anxiety.around exam time but this semester she's.also been coping up with a partner who.she's had for two years her partner is.also studying at the University and she.finds it her to see him around campus.and she noted that she does like to.party with her friends on the weekend.and they'll say that she drinks more.than she would like to when she's out.with her friends so that's just a little.snippet of the case scenario so well.what we want to do now is give you a.note a clinical note and good or bad so.you can read this but I'll just take.some time going through it so this is.one example of how someone wrote the.note that there was a session with Jean.a 25 year old for anxiety chains.attending University studying chemistry.she switched from sociology to chemistry.last year.Jane admits having poor coping skills to.which she drinks too much that she drank.for three days over the weekend and.finding it hard to stay focused on her.schoolwork she finds that she gets.anxious or an exam times and feels this.semester has been overwhelming I think.that Jane is thinking too much about.what her family might think and needs to.concentrate on her own self-care we.discussed some coping strategies so this.is the note that social worker would.have written in the file and so now we.have another poll for you in terms of.what you think about this note would you.consider it a good note and average note.or a Porno so we'll give you another.couple seconds to kind of look at that I.can go back to back to the note there as.well just give another second to to read.through the note back to the poll I know.it's hard to do this online because we.we all want to be talked about.this now hmm sixty five point trees out.it was a poor note 34.7 average no no.one thought it was a good note so that.that's good there's lots of issues with.this particular this particular note and.if we were in a lot of session now I'd.love to get your feedback on that and.how you would actually change that note.but this is some of the pieces that we.pulled it when putting this presentation.together so we do say so in terms of.analysis it says you know that there's a.twenty five-year-old university major in.chemistry so it's not necessary it's not.really relevant to the services delivery.to go into information about her switch.from sociology to from from sociology to.chemistry and was it something really.significant to the anxiety that that.James experiencing we talked earlier.about being clear in our documentation.an example given was poor coping skills.so what really does this mean if.something else were to pick up the file.would they know what we meant when we.said poor coping skills so really speaks.the importance of having statements that.are backed up with facts generally what.does it mean that money is toys how is.this impacting on her in terms of her.anxiety is she able to afford food is.she able to afford her rent is this.contributing to her anxiety so we can.see where there were some gaps left in.the documentation just by using broad.statements that weren't clear in terms.of anyone who is just picking up the.fall and reading it and even in terms of.making a plan for ongoing service.delivery and if making comments about.decline being anxious it's always good.to have those points backed off by facts.so what does this look like and how is.it manifested in her life this one.always get a a charger this one one.thought you know what does it mean to be.drinking for three days that's a very.broad statement.well how many drinks is Jane consuming.is this a problem for her.in her life and is this contributing to.some of the anxiety that she might be.having so being very clear and having.language that's not ambiguous are open.to interpretation or misinterpretation.there was also a personal judgment.statement in there by the social worker.had the social worker had written a Jane.thinks too much about what her family.thinks this could be reverted to say.Jane stated that she worries at what her.family might think if she does not do.well on her exams so just changing it to.to ownership is what Jane is thinking.and now what the social worker is.thinking there the breakup with the.boyfriend or her partner was not.included in the note and while it may.have been addressed in the session this.could be of clinical significance to her.feelings of anxiety and could have been.referenced in the note for example that.she was struggling with a breakup and.the record should also indicate what.coping skills and strategies were.discussed during the session and what.the plan is going forward so we really.need that picture where things are going.is you know in terms of a summary is.there going to be a follow-up was there.a referral made to another professional.for example and it needs to reflect the.professional decision-making of the.social worker so you can see we had the.one case there and these are just you.know several bullets that we pulled out.in terms of things that could have made.the note better and like I said if we.were in a live session we would be.having this broader conversation now.with with you as well in terms of your.thinking around that so we want to we.want to end the presentation then we'll.open up for questions but really in the.presentation with a quote from a kegel.it's an older quote but a goodie from.1995 that staged that recording is more.than a practice skill it involves a.series of important professional.decisions at all levels of the.organization in making each entry.organizing each record and developing.each recording system both workers.consistently constantly balance the.demand for accountability against.equally important goals of efficiency.and client privacy.and I just think that quote is so.fitting so we do have a number of.references that we've included the first.one.Genevieve had mentioned Robert Solomon.he does some fantastic work in Ontario.and the Canadian Association of Social.Workers in 2016 hosted a webinar called.a primer on negligence and documentation.for social workers so if you go on to.that link that's provided in the.presentation you can actually listen to.that that session so I'd recommend that.you do that as well and then the.resources of NASW resources that have.been developed over the years that you.can find on the internet of you website.www.jfn.co.jp/toho all social work.documentation a guy just ranting social.regards threatening a case recording so.those are some really really good.materials if you're interested in in.reading some some more about.documentation so on that note I'll hand.things back to noosa for the question.and answer period.thanks Ann ed and Genevieve we've now.arrived at a question and answer section.and I'll do my best to get to all the.questions however thank you for.understanding if we're in we aren't able.to get to yours our first question is in.the hospital during a recent orientation.I was told the document with exception.hold on hold this concerns me can you.give me some direction hey this isn't it.I can take that that question I think.that's a very interesting one and I.think as because it was done as part of.an orientation.we'll probably recommend going back and.consulting with the team around that and.certainly what that means and if it's.meeting point needs and those kinds of.things so having that discussion within.the organization and some pure.consultation on how to go about doing.that.miss Adele actually in her book it was.that question came you know I looked it.looked up some references did talk about.how the frequency of progress notes are.written really vary from setting to.setting and do depend on agency policy.so it's really good to get an.understanding of what the policy is and.what's meant by that but and it's really.the progress of the case that really.should determine the writing and also.the relevancy of things that are.happening so the relevancy any progress.any critical incidents any significant.changes that may have occurred with the.client any treatment goals that may have.changed any contact with service.providers all those kinds of pieces.would need to be considered and also.then the professional judgment of the.social worker taken in all that.information and and how frequent in the.progress notes should be based on that.if there's really changes and those.kinds of things and the relevancy I.always come back to the relevant.question in terms of is it relevant to.the service delivery and if so it really.should be documented so at the point.that it should be timely documentation.so so that's just some tips that you.might want to consider but really having.that discussion with the team will be.invaluable in terms of okay what is the.policy what does it mean are we meeting.client needs is there anything that.needs to change.stay the same anything that we could do.differently or not and then consider the.points in terms of like as a relevancy.critical incidents progress those kinds.of things.I don't know Genevieve if you had.anything to add today okay all right.okay next question how should I record.when another person other than a client.is mentioned in a clinical conversation.okay I can take that one as well as so.this is another one that really needs to.be explored I think within the context.of of relevant information so what is.the context in which person is mentioned.and how is it important to the service.livery so just go back to that case we.just had in terms of the boyfriend so if.like in the case example we discuss.stache and let's say his name was John.Doe he's age 28 he works at you know.Honda and he just broke up with her it.will probably just be sufficient saying.a note that the clients boyfriend a.partner two years into the relationship.not to go into an owner's amount of.detail in terms of identifying.information for further for the other.person who is not the client so there.wouldn't be need to include that for.example so it does you know come back to.relevancy what information you know the.point that needs to be made in terms of.the context but not necessarily to go.into all the identifying information.okay what would you document related to.the ethical decision making process okay.so that one was actually Genevieve had.actually mentioned that in the.presentation that the ethics committee.had developed an ethical compass on that.topic that was just released last week.so so you can certainly certainly read.through through that at your convenience.but we did talk in that about you know.that's really the record should contain.at you know any ethical decision making.process one would use and we do.recommend another resource that the the.ethics committee produced in 2015 called.the ethical decision making a model.resource tool and so if we look at that.model we would clearly articulate the.dilemma speak twenty values that are in.conflict or relevant from the code of.ethics reference any standards of.practice explore the informed consent.piece again see if it was something that.was addressed an informed consent.no any cultural considerations and also.a document if you had that discussion.with the client in terms of this is.really an ethical dilemma for me and you.know working at it with a client and how.have you had that conversation and any.consultation that that happens with a.manager.or supervisor as well could happen there.but only client care should be included.in the client record so as known in our.standards it's not recommended that you.document disagreements or problems or.issues with a manager or supervisor in.the client file there's other.administrative files for doing that if.there's an issue that needs to be.addressed so only client care should be.addressed in the client records okay.this one might relate a little bit with.that one Annette I work with CSS D as a.frontline social worker in recent years.clinical program supervisors have wanted.to see my note prior to entering them on.the system and have changed the content.this is very concerning but I struggle.with addressing it with management yeah.I think that I don't going to have.that's a very complex question don't.have an immediate answer for that but.it's certainly something that we could.talk about afterwards and even at the.Ethics Committee and you know however I.think that would be worth a conversation.with the team and with management to.kind of look at because that's your note.is your reflection of what happened so.is it the content that's being changed.you know what is exactly that's being.changed and so forth so that will be.worth a conversation actually between.between social worker and the manager in.terms of navigating that issue and and.if there's issues that around.documentation that may need to be to be.looked at in more in more detail here's.another one how important is the.documentation of informed consent all.right I can pass that one over to to.Genevieve.for that one so documentation of.informed consent so documentation of.informed consent is something that we.recommend as part of professional.practice and client care the NASW has.standards for Social Work recording.which notes the social workers must.documents informed consent in the client.record at the beginning of the Social.Work relationship and throughout.the relationship as it becomes necessary.so remember you know informed consent is.a risk management strategy and many.dilemmas can be addressed ethically.through a good informed consent process.so it's a critical piece of.documentation and is critical to the.ongoing relationship that you have with.your client so informed consent is.something that has to be okay.quite continuously and going in to give.it back to a net okay I think this is.probably going to be our last question.because we're running short on time from.what I want to do should clinical notes.be written okay yeah that one actually.came up in our discussion at our.committee room were preparing this.presentation as well so it is.recommended from the literature that.I've looked at that documentation be.written in the third person.so the reflects so that's to ensure.reflection to reflect sorry the.perspective of the client so the social.worker met with the family instead of I.met with the family so but the important.considerations be consistent in doing.that and don't take a little bit of time.to get used to the third person because.it doesn't come to actually the debts.that's how we record but that's what.I've seen from the the professional.literature that it's best to when to do.that from the to write from the third.third person point of view okay I want.to thank Annette and Genevieve for this.wonderful presentation and for sharing.the knowledge and experience with us.today.a lot of important information.pertaining to the standards of practice.for Social Work documentation was.covered and we hope you found the.presentation beneficial all of the.resources highlighted during the.presentation can be asset accessed on.the NASW website WWN LA sWCA under the.practice resources section we encourage.you to take the time to review these.resources and reach out to the NASW or.the ethics committee if you have any.question as social workers we are.committed to providing high-quality.social services as highlighted in the.webinar documentation and service.delivery go hand-in-hand.so thanks again Annette and Genevieve.for putting the spotlight on.documentation today the recording of.this presentation will be uploaded to.the NASW website for your reference for.those who attended 45 minutes or more of.this presentation confirmation of.attendance is available now by clicking.the yellow icon at the bottom right of.your window.I also encourage everyone to complete.the evaluation that will appear on your.screen and thanks again everyone and.enjoy the rest of your day.

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Do military members have to pay any fee for leave or fiancee forms?

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What are the components of a biopsychosocial assessment?

What are the best questions to include in a biopsychosocial assessment? Open ended questions are useful, as they can elicit information that a yes or no question wouldn’t. Here are a few examples: What was your childhood like? How is your relationship with your ____? What was your earliest memory of _____? What makes you come for therapy now as opposed to a few months or years ago? What triggered your _____?

What is included in a biopsychosocial assessment?

What are the best questions to include in a biopsychosocial assessment? Open ended questions are useful, as they can elicit information that a yes or no question wouldn’t. Here are a few examples: What was your childhood like? How is your relationship with your ____? What was your earliest memory of _____? What makes you come for therapy now as opposed to a few months or years ago? What triggered your _____?

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