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Pitfalls for practitioners 4

The size of the record makes it difficult to manage

A common issue for practitioners, managers, supervisors, Children’s Officers, researchers and others who have to read social work files is their sheer size and volume. In recent years the use of standardised recording and assessment formats, such as the Looking After Children materials have been held responsible for much of the increase in the volume of social work files.

However, concern about the size of social work records predates the development of standardised formats and in fact was one of the underpinning reasons for their development (1).

It is important that information is recorded. Of equal importance is that once recorded the information can be easily located. The larger the record the more difficult it becomes to locate key information and identify patterns within the child’s life (2).

When faced with a large, unfocused record practitioners may respond by going prospecting for information. Prospecting practitioners skim through the file. They cannot say at the beginning of their search exactly what information they are looking for, but recognise it when they find it. The danger in this approach is that important information may be overlooked, either because its significance is not appreciated or because it does not conform to the preconceived view held by the practitioner (3).

The record is unfocused

One of the key factors affecting the size of social work records is the number of people who can have access to records. These include other practitioners, supervisors, managers, legal representatives, Children’s Officers, inspectors and family members. Faced with such a large and diverse potential audience making decisions about what should be included in the record is more difficult and it is easy for the record to become diffuse and unfocused (4).

Records are kept to protect the worker

The quality of records has been a key issue in social work inquiries. They have also become increasingly important measures of accountability and the effectiveness of the practitioner and organisation (5). As a consequence practitioners may use the record to try and protect themselves from some future, unspecified challenge. 'Like physicians who have learned to practice defensive medicine, social workers have learned to practice and record defensively' (6). But, as the practitioner is unaware of the nature of any future challenge it is difficult to know what may be safely left out. Taken to its logical conclusion the practitioner must record everything. This is clearly impractical and undesirable. Over recording has the effect of undermining the efficiency of the agency and the privacy of the service user (7).

Minimal records are made

For the same reason that some practitioners may over record, others seek to protect themselves by under recording. The less information on the file the less evidence that can be used against them. This approach can place children at risk of significant harm and can be interpreted as 'a violation of the standard of care' (8).

Practitioners are unclear what is significant

Where a practitioner is unclear what is significant in relation to a child, family or an issue, then the volume of recording is increased as anything of potential significance is included in the record (9).

Records are duplicated in the file

Information is frequently recorded in more than one place in the file (10). This may occur because the agencies' recording formats overlap, or because practitioners feel more confident repeating information than referring readers to information recorded elsewhere in the record (11). In some situations the record may have become so large and disorganised that the practitioner is unclear whether information has already been noted.

In some cases practitioners, in the absence of assessments or summaries, may photocopy information, such as old court and other reports, from earlier volumes into the current file to take their place. Redundant material, such as details of practical arrangements, are retained rather than removed and destroyed.

Records are narrative rather than focused

Traditional social work records were broadly focused. 'Often written in an abstract discursive style for a sophisticated professional audience' (12). Traditional records also tended to be narrative and descriptive. How and what was recorded was left very much to the discretion of the individual practitioner. As a result records were often large, unwieldy and unavailable to any systematic audit (13). To address these issues many agencies developed recording formats aimed at ensuring that essential information was systematically recorded and easily accessible.

Despite the change in emphasis research suggests that many practitioners prefer narrative or descriptive recording. Where the agency recording format does not allow this it is ignored or supplemented with additional recording (14). Narrative recording may be attractive because it is more in keeping with our normal conversational style and patterns of speech. However, it is open-ended and therefore tends to be longer and the practitioner may leave out pertinent information (15), because it is not recognised, does not conform with their view or through lack of time or fatigue.

Avoid the pitfall

  • Maintain a clear focus in your recording. The record should identify the child’s developmental needs, parental capacity to respond to the child’s needs and the impact of family and environmental factors. It should also specify the service to be provided, why this particular service has been selected, the desired outcome as a result of this service and how progress towards this goal will be monitored.
  • Records should record significant information if they are to meet the needs of the child, the practitioner and the agency. However, they should also identify the significance of the information recorded. Use information from research and supervision to assist you to identify the significant information for the particular circumstances of the child and family.
  • Ensure that you have a clear plan for each case and use this to structure both your intervention and your recording.
  • Social work records are an important tool for practitioners. Like any tool therefore,  they should be regularly maintained if they are to fulfil their function. Audit your records regularly to avoid duplication and use summaries, case histories, chronologies or other analytical tools, such as movement charts, to assist in identifying the key issues and maintain a clear direction in the case.
  • Cross reference rather than duplicate.

Activity

Review your files using Audit Sheet 4 (Microsoft Word format).

References

1. Ovreveit J (1986) Improving Social Work Records and Practice. BASW, Birmingham.

2. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190-196. Department of Health (1991) Child Abuse: A Study of Inquiry Reports 1980 - 1989 HMSO, London.

3. Monnickendam M, Yaniv H and Geva, N (1984)) Practitioners and the Case Record: Patterns of Use. Administration in Social Work 18: 73-87.

4. Kagle J D (1984) Restoring the Clinic Record. Social Work 19: 46-50.

5. Social Services Inspectorate (1999) Recording With Care Inspection of Case Recording in Social Services Departments, Department of Health, London

6. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190-196.

7. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190-196.

8. Ames N (1999) Social Work Recording: A New Look at an Old Issue. Journal of Social Work Education  35 227-236.

9. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190-196. Ames N (1999) Social Work Recording: A New Look at an Old Issue. Journal of Social Work Education  35 227-236.

10. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190-196. Ames N (1999) Social Work Recording: A New Look at an Old Issue. Journal of Social Work Education  35 227-236. Edwards R and Reid W (1989) Structured case recording in child welfare: An assessment of social workers' reactions. Social Work 34: 49-52.

11. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190-196..

12. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190-196.

13. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190-196. Ames N (1999) Social Work Recording: A New Look at an Old Issue. Journal of Social Work Education  35 227-236. Edwards R and Reid W (1989) Structured case recording in child welfare: An assessment of social workers' reactions. Social Work 34: 49-52.

14. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190-196. Edwards R and Reid W (1989) Structured case recording in child welfare: An assessment of social workers' reactions. Social Work 34: 49-52.

15. Kagle J D (1982) Social work records in health and mental health organisations: A status report. Social work in Health Care 8: 37-46. Kagle J D (1983) The Contemporary Social Work Record. Social Work 17: 149-153. Kagle J D (1984) Restoring the Clinical Record, Social Work 19: pp46-50. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190-196.

 
 
 
By Steve Walker, David Shemmings and Hedy Cleaver
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