5.4 The Importance of Correct Documentation
Documentation is an important (and often dreaded) part of human service work. Documentation is used for multiple purposes, including case management and billing purposes. Documentation may also be subpoenaed for court proceedings. Documentation helps track our work with clients and assists other workers who may work with the same client.
Many workers treat documentation as an afterthought—a chore that gets quickly done at the end of the day. It is easy to overlook the importance and implications of not only what you document, but how you document. When you document information on your client, you create an official record that can be used later for purposes you may not have intended. Therefore, it is essential to be thoughtful about what you write. It can be just as important (if not more so) than what you do.
The Inherent Power of Documentation
It can be easy to overlook the power you have as an intern. There is always a power difference between those providing services and those receiving services. A human service worker is often in a position to decide who gets services and what services they receive. Even if you, as the worker, do not feel in a position of power, clients will generally assume you have some power in the decision-making process. This power differential has existed since helping became professionalized in the 1880s–1890s. While helping existed in many forms and in many cultures before then, helping started to be recognized as a profession when educated women (mostly White) began developing programs that followed specific guidelines that outlined how clients were served. One of the lasting ideas from that time is that workers are meant to designate between “deserving” and “undeserving” clients. So, even if we do not feel particularly powerful, our clients will always attribute us with power. They will often assume we can decide between offering services or ending services, even if that is not in our job description.
This power differential is most significant in the arena of documentation. Modern social services still exist in the shadow of the white supremacy culture in which it was developed. The history of human services includes ideas of helping people “fit in” or adapt to the norms of the dominant culture. Two of the tenets of this cultural bias still endure in documentation. These tenets are perfectionism and the written word (Okun, 2021).
Perfectionism can be reflected in how much we rely on accurate documentation. There is more focus on pointing out what’s wrong rather than what is right. This may also feed into the observations that you document. You may have an excellent home visit with an elderly person and their caregiver but then only document the negative issues you observed.
The power of the written word is what has driven human services documentation from the very beginning. I was trained early in my career by my first supervisor that “if you don’t document it, it didn’t happen.” Written notes are more highly valued than personal interactions, and most agencies stick to a highly structured format. Not complying with the agency system can result in your work being devalued. Usually, the format focuses on the problems or challenges faced by the client rather than their strengths. In a system that focuses on the written word, you can change the future for your client simply by checking a box.
Put yourself in the position of Sunny, an intern working in child welfare. She has been asked to supervise a custody visit between a mother and her 7-year-old son. During the visit, the son does not make eye contact with his mother and is rather quiet. The mother focuses almost solely on the child’s schoolwork and grades. She inquires repeatedly about whether his foster parents are making him do his homework and checking his answers. Before leaving, she reminds him not to let his grades slip, or his father will be very disappointed. Sunny documents that the child seemed disengaged from his mother and uncomfortable in her presence. Meanwhile, the mother did not ask about her son’s emotional well-being and did not engage in any play. Sunny notes that the mother’s last statement to her son could be interpreted as a threat of consequences for his behavior.
Think about the above situation. At first glance, it may appear that Sunny has done an appropriate job documenting concrete observations. Now add the following details:
- Sunny is from a rowdy Italian-American family that expressed love through physical play and affection. Her mother focused on feeding her children and ensuring their happiness. While education was deemed important, her parents rarely punished or rewarded their children for grades.
- The family being observed are immigrants from East Asia. Their goal in coming to the U.S. was to give their children the opportunity for success and stability not available to them. They believe a good education is their son’s pathway out of poverty. In their culture, children are meant to be obedient and deferential to their parents.
Does this added information change your assessment? How often do we overlook cultural differences that may influence our view? For Sunny, she probably believes she was raised in a “normal” family. For the mother and son, they probably believe their interaction is also perfectly “normal.”
Let’s return to Sunny. She documents the visit and goes on with her day. The case manager sees her note and evaluates the interaction based on her own majority culture background. She becomes concerned that the mother does not understand how to appropriately interact with her child. She recommends mandatory parenting classes and parental coaching. The classes conflict with the mother’s work schedule, so she does not go. The mother is held in contempt and is threatened with termination of her parental rights.
Our case notes can have lasting implications on a client. If our documentation misses critical elements, it is vulnerable to misinterpretation by other workers or agencies involved in the situation. A careless reference to “anger issues” could follow a client through the system for years.
As Kwame Onwuachi (2019) observes in his biography Notes from a Young Black Chef, in grade school, he and his best friend were often pulling pranks and misbehaving. His friend, who was white, would be told, “I’m worried about you getting in more trouble.” In the same situation, Kwame was told, “You are a troublemaker.” He felt like this label followed him from year to year, causing the adults around him to prejudge him in a way that his friend was not judged. We may think our case notes are unimportant, but they may have an impact for years.
Checking Your Assumptions
As McDonald and colleagues (2015) note:
Significantly—and this is not always sufficiently understood by novice or even experienced social workers—those social work reports do more than “communicate.” They also have the power, long past their original purpose, to shape the lives of people (D’Cruz, 2004). Social work reports not only address their intended audiences in a particular (and perhaps local) organization for a specific purpose in the immediate present, but they also have the potential to reach unintended, unforeseen audiences in entirely unpredictable circumstances across vast geographies of space, even many decades later.
So, if we know the dangers of poor documentation, how do we change this? There are many different topics and styles to be aware of, and we list some resources at the end of the chapter. However, two of the most important processes are self-awareness and specificity.
Self-awareness is a type of cultural knowledge rooted in an understanding of our own cultural background. If we are unaware of how our background shapes our worldview, we are susceptible to applying our biased lens to others. What we view as “normal” is often colored by our own history and experiences. Be aware of thinking “Everyone knows…” or “The right thing to do is…”
For example, I come from an Irish-American background. In my family, humor and laughter were used to cope with almost any situation, whether happy or sad. The saying in our household was, “It’s either laugh or cry.” Growing up, I assumed everyone coped in the same manner. As my goal was to work with dying patients and their families, it is exceedingly lucky that I was made aware of this cultural assumption before I began working in the field. I can only imagine how mortifying it would have been to make an inappropriate attempt at humor with a family unprepared for that.
Specificity means using as specific language as possible when describing a situation or a client. When discussing a client’s culture, use the exact culture (Mexican-American, Cuban-American) rather than a blanket label (Latin American). When describing gender identity, use the identity and pronouns used by your specific client. Instead of describing someone as “poor,” use a specific socioeconomic indicator, such as current household income. Be aware that the words you use to describe the situation need to be as clear and free of bias as possible to help prevent them from being misread and misinterpreted. A great resource for inclusive language is the American Psychological Association’s General Principles for Reducing Bias.
Case Study: The Importance of Specificity
Here’s an example of using specificity. Describe what you see in the following picture (figure 5.3).
Now, review what you wrote. Did you include the terms messy, dirty, or unclean? What descriptors did you use? Now, think about how a different worker might view your note. Will they be able to review this kitchen given your description? If they are following up on a complaint, can they tell if the kitchen is different than when you visited? If you are able, compare your description with those of other students. How do they vary? How would you interpret their description? How would they interpret yours?
Specificity will allow other readers the ability to understand the scene and compare it to their own experience.
The Importance of Correct Documentation Licenses and Attributions
“The Importance of Correct Documentation” written by Yvonne Smith with additional sources for inclusive language provided by Michaela Willi Hooper is licensed under CC-BY 4.0.
Figure 5.3. Photo by Aaron G Stock on Flickr is licensed under CC-BY SA 2.0. Modified for size only.
the written record of the interactions between the client and the agency, as well as work done by the agency for the client’s behalf. Documentation often exists as part of an agency’s official records, and may also be used for billing purposes.
the shared beliefs, customs and rituals of a group of people
the act of ending a relationship. Termination in human services generally refers to the methods used by workers to end relationships with clients.
A practice-based profession and an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people