The FAMCare Blog

The Secrets to Better Documentation for Case Workers

Posted by George Ritacco on Jun 9, 2015 1:54:00 PM

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"If it isn't documented, it didn't happen."

This is the cynical mantra of both private and public social service agencies. The limitations of blog space prevent me from retelling countless case histories where a social worker is accused of neglect or wrongdoing by a client or agency and must produce a documented history of client contacts. It is sufficient to note that social workers sometimes find themselves in situations where they must be able to provide evidence of their conduct and actions during some time in the past. This may occur in the context of litigation or adjudication of an ethics complaint filed with a state licensing board or the National Association of Social Workers. Although most social workers understand the importance of careful and thoughtful documentation, some do not. 

Even in the normal course of business, comprehensive records are necessary to assess clients’ circumstances, plan and deliver services, facilitate supervision, and provide proper accountability to clients, other service providers, funding agencies, insurers, and the courts. 

Professional standards now require the following minimum documentation for every client contact: 

  • A social history, assessment, and treatment plan. 
  • Signed consent forms for release of information and treatment. 
  • Notes on all contacts made with third parties. 
  • Notes on any consultation with other professionals. 
  • Notation of canceled appointments. 
  • Summaries of previous evaluations. 
  • Information about fees, charges, and payment. 
  • Reasons for termination and final assessment. 
  • Copies of all relevant documents. 

DOCUMENTATION TEMPLATES

FAMCare case management software provides case workers with the standard and custom templates required to complete the above list of client contact documentation. 

CUSTOMIZED WORKFLOW SYSTEM 

In addition, FAMCare is built on the most powerful workflow and development platform available in the industry. Visions Server, GVT’s proprietary platform, is custom configured for each client making every case management experience unique.   

FAIL-SAFE DOCUMENTATION SYSTEM 

Utilizing FAMCare, agencies can proactively write the work "script" for their case workers by setting alerts and triggers that prevent required documentation from “falling through the cracks”. 

HIPPA COMPLIANT SECURITY 

FAMCare utilizes a multi-dimensional security model that allows for the creation of security groups based on “roles” at your agency. Security protocols and assignments can be set at the user level (so users see ONLY WHAT YOU WANT THEM TO SEE) and at the form level (to hide specific information from some users, but not all). 

The bottom line is that careful and diligent documentation enhances the quality of services provided to clients and, ultimately, can protect practitioners. It would not be difficult to keep up with the documentation required of the modern social worker without FAMCare...it would be impossible.

 

Topics: Global Vision Technologies, Social Services Industry News, FAMCare Tips and Tools

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