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Child Protective Services: A Guide for Caseworkers. 2003
Office on Child Abuse and Neglect, Children's Bureau. DePanfilis, D., Salus, M. K.|
|Year Published: 2003|
Chapter Twelve: Effective Documentation
Case documentation provides accountability for both the activities and the results of the agency's work. In child protective services (CPS), case records and information systems must carefully document: (1) contact information; (2) the findings of the assessments; (3) decisions at each stage of the case process; (4) interventions provided to the family both directly and indirectly; (5) the progress toward goal achievement, including risk reduction; (6) the outcomes of intervention; and (7) the nature of partnerships with community agencies. This chapter describes the primary purposes of record-keeping, principles about the way both paper and automated records should be maintained, and content that should be documented at each step of the process. The strategies outlined here not only assure accountability to others, but also facilitate a way of thinking and a process to measure the results of the agency's work with families and children.163
Purposes of CPS Record-keeping
The key purposes for keeping records are to:
- Guide the CPS process. Case records provide an ongoing "picture" of the nature of CPS involvement with families, the progress toward achieving outcomes, and the basis of decisions that eventually lead to case closure. The process of record-keeping itself helps to clarify and focus CPS work.
- Provide accountability for the agency and the caseworker. Records should describe who is and is not served (including any other household members who may not be participating in services), the kinds of services provided (or not provided due to availability or level of service issues), the basis for all decisions, the degree to which policies and procedures are implemented, and other aspects of accountability and quality control. The record provides a statement about the quality of CPS work that may decrease personal liability should legal action be taken against the agency or a caseworker.
- Serve as a therapeutic tool for the caseworker and the family. Case records can demonstrate the way in which the caseworker and family collaborate to define the purpose of CPS work, including the goals and outcomes that will reduce the risk of maltreatment, and serve to evaluate the progress toward them. Some CPS agencies are using instruments and tools that seek input, and, therefore, the record itself provides an illustration of this collaborative process.
- Organize the caseworker's thinking about the work. Structured presentation of factual information leads to more indepth assessment and treatment planning. Sloppy recording and disorganized thinking go hand-in-hand and will likely lead to poor service delivery to clients.164
In addition to the primary purposes of record-keeping listed above, the case record becomes a means for supervisory review, statistical reporting and research, and interdisciplinary communication.
Content of Case Records
Case records should factually document what CPS does in terms of assessment and intervention, as well as the results of CPS-facilitated interventions and treatment, which serve the outcomes of child safety, permanence, and well-being. Family records, whether paper or automated, should include:
- Information about the nature and extent of the referral or report; identify demographic data on the child, family, and significant others; and the response of the agency to the referral.
- A record of all dates and length of contacts, including in-person and telephone interviews with all family members, collateral sources, and multidisciplinary team, as well as the location and purposes of these contacts.
- Documentation that the family has been informed of the agency's policy on the release of information from the record.
- Information about the initial assessment, including documentation of what may have already occurred (e.g., the report of alleged child maltreatment), as well as the assessment of the risk to and safety of the child.
- Information about any diagnostic procedures that may have been part of the initial assessment (e.g., medical evaluations, x-rays, or other medical tests; psychological evaluations; and alcohol or drug assessments).
- Clear documentation of initial decisions with respect to substantiation of the alleged maltreatment, risk assessment and safety evaluation, basis for any placement in out-of-home care or court referral (if necessary), and reasons for continued agency involvement or for terminating services.
- The safety plan, if one was developed, and documentation of referrals to other programs, agencies, or persons who will participate in the implementation of the safety plan.
- A record of the family assessment (including risks and strengths) and a delineation of the treatment and intervention needs of the child, caregivers, and the family.
- A description of any criminal, juvenile, or family court involvement and the status of any pending legal action in which the client may be involved.
- The case plan with specific measurable goals, as well as a description of the process used to develop the plan.
- Specification of the intervention outcomes, which, if achieved, will reduce the risks and address the effects of maltreatment. These intervention outcomes should lead to the achievement of child safety, permanency, and child and family well-being.
- Documentation of the case activities and their outcomes, including information from all community practitioners providing intervention or treatment (written reports should be requested from all providers) and information about the family's response to intervention and treatment.
- Information about the progress toward the achievement of outcomes, completion of case plans, risk reduction process, and reunification of children with their families or other permanency options.
- Information provided to the court, if court involvement was necessary.
- Inclusion of a case-closing summary that describes:
- outline summarizing the original reason for referral;
- process of closure with the family;
- outcomes and goals established with the family;
- nature of the services provided and the activities undertaken by the various practitioners and the family;
- description about the level of progress accomplished with respect to outcomes and goals;
- summary of any new reports of maltreatment that may have occurred during intervention;
- assessment of risk and safety as it now exists;
- problems or goals that remain unresolved or unaccomplished;
- reasons for closing the case.165
Principles of Record-keeping
The case record is a professional document and tool. As such, it should be completed in a timely and professional manner, and confidentiality should be respected at all times. This means that appropriate controls should be in place to ensure the security of paper and automated files.
- Maintain only information that is relevant and necessary to the agency's purposes. Facts should be recorded and distinguished from opinions. When opinions are offered, their basis should be documented (e.g., Mr. Smith appeared to be intoxicated; his eyes were red; he had difficulty standing without losing his balance; his breath smelled of alcohol).
- Never record details of clients' intimate lives or their political, religious, or other personal views, unless this information is relevant to CPS purposes.
- Record as much information as possible based on direct communication with clients.
- Inform clients about the agency's authority to gather information, their right to participate (or not) in the process, the principal purpose for the use of the information that they provide, the nature and extent of the confidentiality of the information, and under what circumstances information in records may be shared with others.
- Never disclose any verbal or written information about clients to other practitioners without a signed "release of information" prior to disclosure. An exception usually exists in State child abuse-reporting laws to provide for the sharing of information between members of a multidisciplinary team. Specific State laws and policies should guide these actions.
- Retain and update records to assure accuracy, relevancy, timeliness, and completeness. Mark errors as such rather than erasing or deleting them.
- Use private dictation facilities when using dictation equipment to protect a client's right to confidentiality.
- Never include process recordings in case files. The primary purpose of a process recording is to build the practitioner's skills. As such, they do not belong in an agency record.
- Obtain the child and family's permission before audiotaping or videotaping any session and inform the client that refusal to allow taping will not affect services.
- Never remove case records from the agency, except in extraordinary circumstances and with special authorization (e.g., if the record was subpoenaed for the court).
- Never leave case records or printouts from the automated file on desks or in other open spaces where others might have access to them.
- Keep case records in locked files. Keys should be issued only to those requiring frequent access to files. There also should be a clear record of the date that the file was removed and by whom. Similar security procedures (e.g., password-protected) should be provided for automated case records.166
Quality record-keeping is an integral part of professional CPS practice. When the case record is used as an opportunity to organize the worker's thinking and to integrate an approach to measuring the results of CPS work, it becomes an important part of the CPS process rather than something that only documents the process.
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