SWK6405 Social Work Lecture 5: Introduction to Record Keeping PDF

SWK6405 –Social work foundations and fields of practice Lecture 5 | week 5 Introduction to social work collaborative assessment and record keeping  Acknowledgment of Country ECU is committed to p...

SWK6405 –Social work foundations and fields of practice Lecture 5 | week 5 Introduction to social work collaborative assessment and record keeping  Acknowledgment of Country ECU is committed to promoting awareness of and respect for the traditional owners of the land on which ECU meetings, events or teaching and learning is taking place. ECU is committed to reconciliation and recognises and respects the significance of Aboriginal and Torres Strait Islander peoples, communities and histories. Noongar herbal medicine https://upload.wikimedia.org/wikipedia/commons/7/74/Noongar_herbal_medicine.jpg?20191015114412 Natalia2323, CC BY-SA 4.0 , via Wikimedia Commons  SWK605 Session Topics Week 1: Introduction to social work and this unit Week 2: Historical, social and political contexts Week 3: Knowledge bases of social work Week 4: Introduction to theories (this is covered in detail in SWK6410 Social Work Theory and Ethics) Week 5: Introduction to social work record keeping – collaborative strength-based assessments and case notes Week 6&7: Working with violence, abuse and trauma Week 8: Working with addiction Week 9: Working with children and young people in diverse families Week 10: Working with older persons Week 11: Anti-racist approaches Week 12: Organisational contexts of social work practice Week 13: Review Unit Learning Outcomes 1. Critically reflect on the values of social and ecological justice across varying fields of social work practice. 2. Apply cognitive and practice skills to investigate and evaluate the full range of practice domains within a specific field of social work. 3. Apply communication and collaboration skills to develop effective change strategies for a specific field of practice to articulate social and /or ecological justice in practice. 4. Critically reflect on and understand the use of self in social work practice in a specific field of practice to develop an assessment report exhibiting respect for diverse belief systems. Topic Learning Outcomes By the end of this topic (including readings, narrated power point and the class) you aim to be able to: Argue the relevance and importance of organisational theory and analysis as a component of social work practice. Explain the core principles of key theories applicable to organisational analysis and how they relate to social work practice. Apply theory in order to analyse the systems and processes of organisations and how these may impact clients and service delivery, with particular focus on identification of barriers and injustice. Appraise the need for change within organisations and describe appropriate and reasonable steps for implementing organisational change in order to reduce social barriers, inequality and injustice.  Lecture Record keeping Progress notes or case notes Social work assessment Traditional vs strengths-based assessment Collaborative assessment Theories and values underpin assessment Bio-psycho-social-spiritual assessments Working respectfully with Indigenous Australian people Using critical reflection and process orientations across the four phases of the helping relationship Collaborative assessment is not possible without respectfully using the micro-skills to work across the four interrelated and sometimes recurring phases of the helping relationship.  Process – orientations (micro-skills) Ten groups of ‘Process Orientations’ (micro-skills): Clear contracting, use of agency and discretion and 'expanding boundaries‘ Critical questioning, deconstruction, reflectivity and reflexivity Cultural humility Culturally friendly attitude Resisting, witnessing and validating Research, policy analysis and advocacy Universalising, individualising and externalising Mutual consciousness-raising Deep, respectful ethical listening, stillness [and use of silence] Dialogical praxis (Hosken & Goldingay 2016 pp. 56--59)  Good record keeping is essential in social work Professional written communication skills are as important as verbal and non-verbal communication skills. A range of recording forms and methods exist, which differ according to fields of practice and legislative mandates and principles Organisations have record-keeping requirements to ensure worker transparency, consistency and accountability in practice and use sophisticated record-keeping software programs and protocols to this end. Record keeping must comply with relevant privacy and confidentiality legislation and procedures. All agencies have different policies procedure and ways they keep records Can include intake forms, progress notes or case notes that summarise contacts with services users, assessments, letters, emails (Maidment et al., 2022, p.78) Ongoing progress notes or case notes Are used to: provide a record of day-to day actions record action plans discussed and agreed upon between the worker and service user record factual detail for future reports or assessments support service continuity for the service user when new workers become involved fulfill legal requirements facilitate accountable and transparent practice with service users and within the agency (Maidment et al., 2022, p.79) Ongoing progress notes or case notes Format Brief and factual Information written is substantiated while not being judgemental or prejudicial. Legal reports, organisational assessment or letters generally require a fuller format based on organisational mandate. Be aware that other professionals and often service users will read your case notes (Maidment et al., 2022, p. 79) Case notes https://youtu.be/caDeeZaY-e0?si=_SGUr3XmxfQJaXxq What is a social work assessment The traditional forms of social work assessment were influenced by the medical model, focus on pathology and problems, linear thinking, and presumed the social worker as an expert making the assessment and plan. In contrast, we promote assessment as a collaborative process ‘Social workers need, in their assessments, to listen to people, validate their experiences and work collaboratively to promote service users’ strengths. … [This] approach allows for multiple and diverse understandings developed in the particular context of the individuals involved. The models developed by Milner et al. (2020) and Fook (2016) use a narrative approach that is constructed with the service user and is open to change and development. Assessment becomes a process of dialogue rather than fact- finding. It is also important not to be bound by restrictive assessment proformas but to question what information is needed, why it is needed and to what uses it might be put”. (Parker, 2020, p.10). What is a social work assessment (Maidment et al., 2022, p. 139) Collaborative assessment ‘we advocate for a process of collaborative assessment, that acknowledges and seeks to redress the impact of the socioeconomic context from which current problems arise, while at the same time endeavouring to mobilise client resources, both internal and external. Internal resources are those related to coping, motivation, intellectual functioning, decision-making, hope, faith and self-esteem. External resources are those found in the environment around the client and client system. These include relationships with friends, family, community and cultural networks, formal support services and spiritual Associates’. (Maidment et al., 2022, p. 79) Collaborative assessment (McAuliffe, Boddy & Chenoweth, 2023, p.225) ‘ (McAuliffe, Boddy & Chenoweth, 2023, p.224) ‘ Components of social work assessment Assessment involves a process of information gathering about significant factors impacting a person, family, group, organisation or community, then... Organising and interpreting the information using critical thinking skills. Applying knowledge from a range of perspectives, including understandings of life course trajectory and ecological systems theory to gain an understanding of the service user, family, group or community positioning. Identifying and assessing service user strengths and areas for change. Developing a mutually agreed-upon plan with goals for intervention and selecting appropriate intervention strategies. (Maidment et al., 2022, p. 79) Bio-psycho-social-spiritual assessments ‘a shared approach to gathering information and shared understandings of how Aboriginal ways of knowing, being and doing, and bio-psychosocial assessments can collectively form a holistic social and emotional wellbeing assessment of the whole of person This may include; » content on cultural connections, safety, environment, health, spirituality, mental health » connection to family and kinship » connection to land waters and skies » Aboriginal parenting practices and experiences of being parented and how they parent » stories of connection to ancestors » systemic factors and historical experiences of past events, policies, and practices » community support and strengths in culture. Assessments that support and record this shared information will provide holistic perspectives of the family and weave a rich picture of culture and clinical aspects that will inform culturally responsive ways of working with families. This requires each team member’s knowledge base to be equally valued in the social and emotional wellbeing assessment. Time spent together as a team to formulate the assessment is considered best practice that will have a positive impact on the specific needs of a family’ (Shen & Young, 2022, p.11)  Working respectfully with Indigenous Australian people To work respectfully with Indigenous Australian peoples and peoples who are different from themselves, students need to critically analyse their preconceived assumptions and be open to learning how to make connections with people based on respect. Following are key concepts to assist readers appreciate the use and context of ‘Respect’ and to lay the foundation for basic manners to be learned when working with Australia’s First Nations peoples. Equality Respect is based on the fundamental ‘truth’ that all people are equal. To give an example, a professor’s soul (for want of a better word) is equal to that of a person living rough. Issues such as behaviour, responsibilities, and age are recognised, but the basic essential worth of each individual is the same. Reciprocity Mutual benefit is expected, based on the concepts of respect and equality outlined previously. Rather than being imposed, such reciprocity encourages respectful sharing. There can be a power imbalance when social workers and those in other helping professions are working with service users. Reciprocity helps to even out any imbalance by encouraging respectful dialogue and exchange of power. Asking oneself what you can exchange when engaging with a service user places an emphasis on seeking value in the other’s words along with thoughtfulness in your own. Reciprocity acts as an incentive to listen more respectfully to what is being shared with you so that you can reciprocate with appropriately sharing your relevant professional knowledge.  Working respectfully with Indigenous Australian people To work respectfully with Indigenous Australian peoples and peoples who are different from themselves, students need to critically analyse their preconceived assumptions and be open to learning how to make connections with people based on respect. History Knowledge and use of history are features of Indigenous ways of working. Select, relevant, and thoughtful use of history is important, as it sets the context for discussion and demonstrates that you have taken the time to become informed. It is not acceptable for human service professionals to claim they do not know the history of Australia, especially with the ample knowledge available in texts, in the media, and on the internet. Spirituality Spirituality is a significant aspect of Indigenous Australian’s worldview and private and professional lives. Spirituality incorporates Country as a sentient being and what is known as The Dreaming (Muller, 2014). In this chapter, The Dreaming is only mentioned briefly so that students can be aware of its importance. It is worth being conscious that a worker does not have to believe in, agree with, or understand the intricacies of another’s spirituality or spiritual beliefs in order to respect the importance of them to the person. (Muller, 2020, pp. 41-42)  Good case notes What is a “good” case note? accurately describes an individual, family’s or group’s experience in relation to the issues of concern which prompted their referral or approach to your organisation. outlines the matters which are important to their short or long-term care and/or support and maintains an account of the decisions made and the actions taken in relation to their lives. provides opportunities for the client or clients to collaborate and participate in this decision-making and recording process, by reflecting with supportive professionals on accurately recorded incidences and patterns. not only contains the correct content, but considers how the information is framed, worded and used. For this reason, it is important to consider what you write in your case notes, how you write your case notes and what messages they might convey. Assume that clients and other workers will read and rely on your case notes. (Peakcare & QCOSS, 2023)  Strength-based case notes Using a strengths-based approach to writing can help you actively commit to recording information that is accurate and complete. Accurate case notes provide a true and specific account of events, decisions or actions that are taken or planned. They recognise that truth may sometimes be based on perception. The strengths-based case note writing approach requires that information is recorded in ways that promote open and ongoing enquiry and the possibility of hope. It recognises that, in many instances, those who seek out, come to the attention of, or are referred to your organisation for a service, will already hold perceptions of themselves as dysfunctional or inadequate and be experiencing a sense of hopelessness and despair. Strengths-based case note writing does not confirm or exacerbate the negative perceptions a person might have about themselves. Instead, it introduces them to the possibility of hope through open and ongoing enquiry about, and discovery of, their unique strengths and resilience. Use of a strengths-based approach requires that information is not recorded or presented in a way that further labels individuals as failures or inadequate or confirms their own thoughts about this. It also requires information to be framed and presented in ways that reflect the writer as someone who is standing with the person and standing against the issues of concern that are impacting their life. (Peakcare & QCOSS, 2023)  Strength-based case notes Examples of deficit- and strengths-based case notes To understand how powerful framing can be, below are examples of a deficit-based and strengths-based case note about the same person. Deficit-based case note Mary Bloggs is an incompetent and inadequate recorder of case notes. She is inadequate in terms of her knowledge, skills, and experience in being able to record case notes properly. Strengths-based case note Mary Bloggs is experiencing difficulties in recording case notes. With only a few months experience and having not yet received all the information and training Mary needs to gain knowledge about recording case notes, this is currently getting in the way of Mary being able to build her skills and demonstrate all of the competencies required for this area of her work. While the deficit-based case note presents Mary’s issues of concern as symptomatic and confirmation of her personal incompetence and inadequacy, the strengths-based case notes frames Mary and the writer as standing together against the issues of concern. The reader’s perception of Mary after reading the strengths-based case note is framed in a way that identifies opportunity for bolstering points of strength. The case note identifies tangible issues to be addressed rather than discounting any hope that Mary can change. (Peakcare & QCOSS, 2023)  Strength-based case note writing do’s and don’ts do use respectful language don’t use value-laden, judgmental conclusions and expressions of personal opinion do provide clear descriptions do use key terminology appropriately do be aware of distinctions between “swearing” and “abusive” language do take custom and context into account do think beyond the “words you hear” to a position of “actively listening” to the intentions and “real meaning” of words don’t quote swear words if they “confuse” rather than “clarify” and misrepresent the person quoted do be aware that quotes may become subject to value-laden, personalised interpretations by the reader do write clearly– avoid non-specific or misleading words and phrases don’t use abbreviations and “text-message” spelling don’t use an acronym without first ensuring that the full title has appeared followed by the acronym in brackets do show the reader rather than tell them the information you are trying to communicate. (Peakcare & QCOSS, 2023) Strength-based case notes Examples of how to write in a way that shows, not tells “Chris was obviously angry” goes only part of the way towards providing a clear description. It may “tell” the reader some information about Chris, but it doesn’t “show” the reader in what ways it was made obvious that Chris was angry. A better and clearer description (such as “Chris appeared angry, evidenced by his raised voice and behaviour in pacing up and down the interview room”) both tells and shows the reader the relevant information. Making effective use of the term “appears” to describe those things that were observable to you (e.g. “Chris appeared restless”). Use “seems” to describe impressions that you formed based on cumulative information (e.g. “Chris seems like a highly intelligent young man”). Qualifying comments frequently follow observations that reflect the worker’s impressions, showing that the worker is not sure but suspects something might be true. (e.g. “Chris hesitated to answer, which could indicate he wasn’t certain.”) (Peakcare & QCOSS, 2023) ‘ Fundamental principles of person-centred strength-based case notes Keep the Person at the Center Always prioritise the person you're writing about Consider how your documentation impacts their life and dignity Remember: These records may be read years later by the person themselves Every word choice matters - they shape narratives and memories Records are not just administrative tools but part of someone's life story The Power and Importance of Names Names are fundamental to identity and dignity For some in care, their name may be their only constant possession Accuracy in spelling and usage is crucial (O’Keefe & McLean, 2023, pp.87-89 Kindle) Fundamental principles of person-centred strength-based case notes Consider Your Future Reader Records will likely be read by the person they're about Avoid clinical or dehumanising language Challenge: Balance professional documentation with human dignity Impact of word choice on self-perception Think about how your writing might affect someone years later Aim for clear, respectful, and empathetic language Best Practices for Record Writing Avoid copy-pasting - each entry should be thoughtful and original Include positive observations and achievements Document growth and progress Even when nothing has changed, take time to write meaningfully Show reflection and careful observation in your notes (O’Keefe & McLean, 2023, pp.87-89 Kindle) Fundamental principles of person-centred strength-based case notes Technical Aspects of Record Keeping Proper redaction procedures are crucial Double-check all hidden information Consider impact of seeing redacted information on the reader Maintain consistent quality in documentation Follow legal and organisational guidelines Letter-writing format becoming more common (O’Keefe & McLean, 2023, pp.87-89 Kindle) Fundamental principles of person-centred strength-based case notes Impact of Quality Documentation Records shape perceptions and memories Documentation can heal or harm Your words may be read decades later Quality documentation shows respect and care Every record entry is part of someone's story Challenge yourself to write with empathy and clarity (O’Keefe & McLean, 2023, pp.87-89 Kindle) ‘  Strength-based case notes- The Data, Assessment, Plan (D.A.P) framework There are multiple case note writing frameworks which can guide how you approach and write case notes and your organisation may have a preferred methodology. The D.A.P framework is a simple, easy-to-remember tool for recording accurate and authentic case notes. Below are explanations of what is meant by each term and questions that will help you gather useful, accurate content. Data Data may be both subjective (what the person says or feels) and objective (observable behaviour). The following questions are useful to answer when gathering data. what did the person say or do during the contact? what did you observe? what happened? where did it happen? when did it happen? what was the order of events? who was involved? (Peakcare & QCOSS, 2023, p.7) The D.A.P Framework (a sample template) (Peakcare & QCOSS, 2023, p.8) Thompson’s (2012,pp. 32-48) PCS analysis (as adapted by Hosken) Individual (personal and psychological) level Individual/family/group/community level of thoughts, feelings, attitudes and actions. Includes how workers interact with each other, and with service users, families, groups and communities, and the need for workers to guard against their own complicities and prejudices. Social (cultural) level Shared ways of seeing, thinking and doing. Common values and patterns of thought and behaviour, consensus about what is ‘right’ and ‘normal’. People internalise social values and norms via ongoing socialisation and, for social workers, ongoing professionalisation. Where do workers and clients get the messages from about who is a ‘good’ worker, a ‘good’ person, a ‘good’ mother/ father/ family / community? Whose voice/view is privileged, able to set the normative standards against which others are judged? How are people furthest from the mythical norm standards treated? Structural / political level Refers to the historically created network of social divisions and the power relations that are associated with them as embedded in institutions and societal arrangements. Includes past as linked to current political-economic-socio-historical dimensions of power and influence. Reference List (cont.) Australian Association of Social Workers (AASW). (2015 updated 2016) Ethics and practice guideline- case notes Maidment, J., Egan, R., Tudor, R., & Nipperess, S. (2022). Practice skills in social work and welfare: More than just common sense (4th ed.). Taylor & Francis. O’Keefe, R., & Maclean, S. (2023). Case Recording in Social Work with Children and Families: A Straightforward Guide. Kirwin Maclean Associates. Muller, L. (2020). Preparing to work with Aboriginal and Torres Strait Islander peoples: Decolonisation for social work practice. In Practice Skills in Social Work and Welfare (pp. 84-100). Routledge. Parker, J. (2020). Social work practice: Assessment, planning, intervention and review (6th ed.). Learning matters. Peakcare & QCOSS (2023) How to write case notes. Queensland Council of Social Service Ltd. Shen, D., & Young, S. (2022) Safer Family Services: Aboriginal Cultural Practice Framework. Government of South Australia The end.