Child Protective Services: A Guide for Caseworkers

1 CHAPTER 12. Effective Documentation C ase documentation provides accountability for both the activities and the results of the agency's work. In Child Protective services (CPS), of record-keeping itself helps to clarify and focus CPS work. Provide accountability for the agency and case records and information systems must carefully the caseworker. Records should describe who is document: (1) contact information; (2) the findings and is not served (including any other household of the assessments; (3) decisions at each stage of members who may not be participating in the case process; (4) interventions provided to the services ), the kinds of services provided (or not family both directly and indirectly; (5) the progress provided due to availability or level of service toward goal achievement, including risk reduction;. issues), the basis for all decisions, the degree to (6) the outcomes of intervention; and (7) the nature which policies and procedures are implemented, of partnerships with community agencies.

2 This and other aspects of accountability and quality chapter describes the primary purposes of record- control. The record provides a statement about keeping, principles about the way both paper and the quality of CPS work that may decrease automated records should be maintained, and personal liability should legal action be taken content that should be documented at each step of against the agency or a caseworker. the process. The strategies outlined here not only assure accountability to others, but also facilitate a Serve as a therapeutic tool for the caseworker way of thinking and a process to measure the results and the family. Case records can demonstrate of the agency's work with families and the way in which the caseworker and family collaborate to define the purpose of CPS work, PURPOSES OF Child Protective services including the goals and outcomes that will reduce the risk of maltreatment, and serve to evaluate RECORD-KEEPING.

3 The progress toward them. Some CPS agencies are using instruments and tools that seek input, and, The key purposes for keeping records are to: therefore, the record itself provides an illustration of this collaborative process. Guide the CPS process. Case records provide an ongoing picture of the nature of CPS Organize the caseworker's thinking about involvement with families, the progress toward the work. Structured presentation of factual achieving outcomes, and the basis of decisions information leads to more in-depth assessment that eventually lead to case closure. The process and treatment planning. Sloppy recording and Child Protective services : A Guide for Caseworkers 101. 101. disorganized thinking go hand-in-hand and will maltreatment, risk assessment and safety likely lead to poor service delivery to evaluation, basis for any placement in out-of- home care or court referral (if necessary), and In addition to the primary purposes of record- reasons for continued agency involvement or keeping listed above, the case record becomes a for terminating services .

4 Means for supervisory review, statistical reporting and research, and interdisciplinary communication. The safety plan, if one was developed, and documentation of referrals to other programs, agencies, or persons who will participate in the CONTENT OF CASE RECORDS implementation of the safety plan. A record of the family assessment (including Case records should factually document what CPS. risks and strengths) and a delineation of the does in terms of assessment and intervention, as treatment and intervention needs of the Child , well as the results of CPS-facilitated interventions caregivers, and the family. and treatment, which serve the outcomes of Child safety, permanence, and well-being. Family records, A description of any criminal, juvenile, or whether paper or automated, should include: family court involvement and the status of any pending legal action in which the client may be Information about the nature and extent of the involved.

5 Referral or report; identify demographic data on the Child , family, and significant others; and the The case plan with specific measurable goals, response of the agency to the referral. as well as a description of the process used to develop the plan. A record of all dates and length of contacts, including in-person and telephone interviews Specification of the intervention outcomes, with all family members, collateral sources, and which, if achieved, will reduce the risks and multidisciplinary team, as well as the location address the effects of maltreatment. These and purposes of these contacts. intervention outcomes should lead to the achievement of Child safety, permanency, and Documentation that the family has been Child and family well-being. informed of the agency's policy on the release of information from the record. Documentation of the case activities and their outcomes, including information from all Information about the initial assessment, community practitioners providing intervention including documentation of what may have or treatment (written reports should be already occurred ( , the report of alleged Child requested from all providers) and information maltreatment), as well as the assessment of the about the family's response to intervention and risk to and safety of the Child .

6 Treatment. Information about any diagnostic procedures Information about the progress toward the that may have been part of the initial assessment achievement of outcomes, completion of case ( , medical evaluations, x-rays, or other plans, risk reduction process, and reunification medical tests; psychological evaluations; and of children with their families or other alcohol or drug assessments). permanency options. Clear documentation of initial decisions Information provided to the court, if court with respect to substantiation of the alleged involvement was necessary. 102 Effective Documentation Inclusion of a case-closing summary that intoxicated; his eyes were red; he had difficulty describes: standing without losing his balance; his breath smelled of alcohol). Outline summarizing the original reason for referral; Never record details of clients' intimate lives or their political, religious, or other personal Process of closure with the family; views, unless this information is relevant to CPS.

7 Purposes. Outcomes and goals established with the family; Record as much information as possible based on direct communication with clients. Nature of the services provided and the activities undertaken by the various Inform clients about the agency's authority to practitioners and the family; gather information, their right to participate (or not) in the process, the principal purpose for Description about the level of progress the use of the information that they provide, accomplished with respect to outcomes and the nature and extent of the confidentiality of goals;. the information, and under what circumstances Summary of any new reports of information in records may be shared with maltreatment that may have occurred others. during intervention;. Never disclose any verbal or written information Assessment of risk and safety as it now about clients to other practitioners without exists; a signed release of information prior to disclosure.

8 An exception usually exists in State Problems or goals that remain unresolved or Child abuse-reporting laws to provide for the unaccomplished; sharing of information between members of a multidisciplinary team. Specific State laws and Reasons for closing the policies should Guide these actions. Retain and update records to assure accuracy, PRINCIPLES OF RECORD-KEEPING. relevancy, timeliness, and completeness. Mark errors as such rather than erasing or deleting The case record is a professional document and tool. them. As such, it should be completed in a timely and professional manner, and confidentiality should be Use private dictation facilities when using respected at all times. This means that appropriate dictation equipment to protect a client's right to controls should be in place to ensure the security of confidentiality. paper and automated files.

9 Never include process recordings in case files. Caseworkers should: The primary purpose of a process recording is to build the practitioner's skills. As such, they do Maintain only information that is relevant and not belong in an agency record. necessary to the agency's purposes. Facts should be recorded and distinguished from opinions. Obtain the Child and family's permission before When opinions are offered, their basis should audiotaping or videotaping any session and be documented ( , Mr. Smith appeared to be inform the client that refusal to allow taping will not affect services . Child Protective services : A Guide for Caseworkers 103. Never remove case records from the agency, the date that the file was removed and by whom. except in extraordinary circumstances and with Similar security procedures ( , password- special authorization ( , if the record was protected) should be provided for automated subpoenaed for the court).)

10 Case Never leave case records or printouts from the Quality record-keeping is an integral part of automated file on desks or in other open spaces professional CPS practice. When the case record where others might have access to them. is used as an opportunity to organize the worker's thinking and to integrate an approach to measuring Keep case records in locked files. Keys should the results of CPS work, it becomes an important be issued only to those requiring frequent access part of the CPS process rather than something that to files. There also should be a clear record of only documents the process. 104 Effective Documentation CHAPTER 13. Supervision, Consultation, and Support C hild Protective services (CPS) supervisors are responsible for ensuring that the agency mission and goals are accomplished, and that positive Helping staff learn what they need to know to effectively perform their jobs through orientation, mentoring, on-the-job training, and outcomes for children and families are achieved coaching.