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case management, Casework, mental health, Mental health blog, social work

How to document like a pro

This is the fourth post in the Casework 101 series by Social Workin It. Read the previous post here: 3 tips to co-create an engaging case plan.

Documentation is the process of showing your work. It’s an integral part of case management. However, there are right and wrong ways to do it. It can either protect your client, you, and your agency or leave you all at risk. This is why it’s a crucial skill to learn and commit to developing throughout your career. 

Having said that, I have prepared some pro tips to guide you, based on my education and experience as a case manager.

Why we document

Woman in yellow shirt holding file folders while standing outside.

To begin, let’s look at why it’s so important to document your work.

First, it ensures a continuity of service. If you fall ill, take a vacation, or have to leave work unexpectedly (temporarily or permanently), documentation provides all of the necessary information your colleagues need to pick up where you left off. The file should contain your assessment and case plan, as well as a clear overview of everything that’s been completed on the file to date and the outcomes of that work. That way, the next person working on the file can jump right in without skipping a beat and your client’s service won’t suffer significantly.

Second, it ensures accountability in three key ways. One, it keeps you accountable to the client. You agreed to provide a service and your documentation of that work is how you demonstrate your commitment and adherence to that agreement. Two, it keeps the client accountable to you if there is ever a disagreement about what was discussed. And three, it keeps you accountable to your regulatory college. If your credibility or ethics were ever called into question through a formal complaint process, your documentation is all that you have to support your side of the story. This can either make or break your case.

Third, it is evidence of the services you provided. This evidence can be used in reports to funders or your agency’s Board, new funding applications, community presentations, training sessions, etc. Without evidence, we have no way to show how valuable our work is. Documentation of all the good work you do can help make the case for why this work should continue. Additionally, it can help others to start similar programs in their own agencies or communities, which is basically the professional equivalent of paying it forward.

Finally, it allows you to evaluate your work. Without continual reflection, you cannot grow and improve your work and services. Having clear documentation of the work you have done allows you to see opportunities for improvement at both the individual and program levels.

Now, that you know why you should document, it’s time to review what you should document.

What we document

Notepad and pen on wooden table with coffee and branch of holly.

While you won’t be able to Google search an exhaustive list of all the things you should document, mainly because mental health roles are so varied and contextual, I have attempted to compile at least an extensive list of possibilities based on my own experience as a case manager. Some of these items may not apply to your particular practice, but here is a list of some of the things you should document if they do apply to you:

  • Appointments (including missed)
  • Assessments
  • Case plans
  • Consents and authorizations
  • Agreements
  • Contracts
  • Reports
  • Progress notes
  • Correspondence (faxes, emails, letters, etc.)
  • Conversations (in-person, telephone, text, etc. and with absolutely everyone you talk to about the file, such as the client, their family or friends, other workers in their life, your colleagues, other agency professionals, etc.)
  • Case consultations
  • Memos (I use a very basic memo template for all documentation that does not exist as a hard copy already, which you can download for free at the end of this article)
  • Notes (including hand-written)
  • Genographs
  • Audio or video recordings
  • Advice given
  • Research
  • Referral forms and documents
  • Critical incidents and your responses
  • Any documents you receive (from the client or anyone else)

Basically, you should document any work you have done on a file. As the saying goes: if it’s not written down, it didn’t happen.

Once you know what to document, the next step is to learn how to document.

How we document

Person's hand writing in notebook while other hand holds coffee mug that says "be happy".

Three people to keep in mind

When trying to determine what details to include in your documentation, there are three people to keep in mind: the client, you, and your colleagues.

If your case file was ever subpoenaed in a court case against your client, how is your client going to look? You have to be careful about how you portray them. Stick to objective facts as much as possible. Don’t include anything that is not necessary for your work with them. When you must describe behaviours or incidents, be mindful of how you describe these. Be sure to uphold your client’s integrity and safety at all times.

If your case file was ever subpoenaed in a court case against you, how are you going to look? You need to be careful to document everything you do on a file so there is a paper trail of every discussion had, decision made, and action taken. If you have to explain yourself, will you have the evidence to back up what you say? Make sure you do, by having solid documentation.

If you stopped working suddenly, would someone be able to pick up your file and know exactly what happened? Would they easily be able to pick up where you left off? Your documentation, when done well, can ensure there are no major disruptions in your client’s service and that your colleagues have all of the information they need to best support the individual in your absence. 

Best practices

Documentation can be overwhelming when you are first starting as a case manager. Heck, I still find it overwhelming sometimes! There’s a lot at stake. It gets easier with practice and it’s made even easier with best practices, which we have now thanks to all of those who came before us. Here is a list of the key best practices I have learned and exercised over the years:

  • Document absolutely everything relevant to the file
  • Be objective unless subjective notes are justified (think of the three people you need to keep in mind – sometimes subjective notes are important to protect/help those people)
  • Avoid jargon
  • Define acronyms when you first use them in a document
  • Document as soon as humanely possible (and no longer than 24 hours unless absolutely unavoidable)
  • Adhere to the goldilocks rule for content – not too much and too little, but juuuust right (aka concise yet thorough)
  • Schedule time for case notes every day (always document as soon as possible but, when you can’t, use this block of time instead)

If you adhere to these tips, you will be well on your way to becoming a documentation rock star!

Storage

Desk with storage drawers on both sides. Desk and drawers have computer, books, typewriter, globe, plant, and a notebook on them.

It is as important to think about the storage of your documentation as the documentation itself. If something were to happen to your files, then all that beautiful documentation will be useless to you. It is necessary to ensure a secure storage procedure that protects client confidentiality and that ensures all of this important information does not get lost. Keep files in a secure location, backup your work, and follow the necessary storage and privacy policies of your organization and your province/state and country. When in doubt, speak to your manager, your regulatory college, and/or a Lawyer.

Conclusion

I hope I’ve made it clear just how important documentation is as a case manager. This is something we should never truly be fully comfortable with. I am far more concerned about people who think they already know everything about documentation than about students and new case managers. Newbies tend to be more deliberate and cautious about documentation than seasoned veterans, which is a good thing. We must never become complacent about this skill. After all, the golden rule of case management is document, document, document! Don’t ever forget that and you’ll be fine.

Resource

As promised, you can download my free memo template below! Feel free to use and adapt it for your own needs. This is the actual document I use in my daily practice as a case manager.

Download available here:

Disclaimer: Tina Cumby is a Social Worker in Ontario Canada. As such, some of the advice in this article may reflect the particular ethical guidelines for social workers in Ontario Canada. When in doubt, refer to the ethical guidelines of your particular mental health profession and the state or province you are licensed to practice in.

Tina Cumby, MSW, RSW
Tina Cumby, MSW, RSW

Tina Cumby, MSW, RSW, is an independent writer and creator of free content for mental health professionals. She has been employed as a social worker for four years and has another year of case management and policy development experience. She works primarily with adults living at the intersections of poverty, disability, and trauma at all levels of practice (micro, mezzo, and macro). Tina is particularly well versed in social work case management and student supervision.

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