§5 ch1: Documentation And Record Maintenance
1.3 Recording Guidelines
1.3.1 Definition, Purpose, Style
The family record shall summarize all activities, including family strengths, efforts to address safety and risk issues, and a summary of the activities of any treatment agents and/or family support teams. The record must also include the family’s involvement in and reaction to services provided.
The guidelines listed below are intended to provide a basic structure for capturing relevant information. They are designed to serve as a general framework for all recording. Emphasis is placed on being purposeful, specific, factual, and focused on the investigative, assessment and/or treatment process. The Children’s Service Worker and supervisor are free to modify certain components, when appropriate, in order to accommodate the needs of specific situations.
The Children’s Service Worker’s use of “I” (first person pronoun) is preferred when describing his/her activities. This conveys a sense of ownership and accountability. Avoid using third person descriptors, such as “worker” for this purpose.
1.3.2 Recording Guidelines – Investigations
All CA/N investigation narrative recording is done on the CPS-1 and supplemental pages. Handwritten notes should be destroyed. Handwritten notes should only be maintained as part of the record if they are necessary as evidence to meet the Preponderance of Evidence standard for abuse/neglect. Any information maintained is subject to subpoena and the Children’s Service Worker should keep this in mind when completing the investigation. Narrative recording serves as a means for the worker to document all investigative activities. It also assists the worker in making decisions by:
- Enhancing communication between the worker and supervisor;
- Serving as documentation of the worker’s decision; and
- Gathering all information in one place to facilitate decision-making.
The investigative record aids the Children’s Service Worker in planning for and conducting the investigation. In addition, it provides valuable information to staff who are subsequently assigned to provide services to the family. Thorough narrative recording will also demonstrate compliance with agency policy and legal mandates.
The purpose of narrative recording of CA/N investigations is to:
- Provide a chronological list of all the investigator’s activities related to the investigation;
- List the facts and direct observations obtained by the investigator during the investigative process; and
- List the evidence that supports the facts.
To accomplish these objectives, the narrative must be thorough, accurate, clear, specific, timely, and factual.
- Thoroughness: The investigator must secure and record all information necessary to make critical decisions affecting the conclusion. Narrative recording is thorough when it answers the following questions for the reader: who, what, when, where, why, and how the incident occurred. Some information, particularly reports from law enforcement/prosecution, may not be available to staff when the investigation is completed. Update the information at a later time, as the information becomes available.
- Accuracy: Descriptions of observations, physical evidence, and statements must be recorded with accuracy and in detail. The following is a seven-point review, which is a good test of the accuracy of narrative recording:
- Is the data contained in the recording accurate?
- Is the data contained in the recording complete?
- Are there persons or places in the report for which full identifiers are not given?
- Are the events described in the recording understandable in that they are in proper sequence and the chronology is clearly set forth?
- Are all articles of evidence, whether obtained by worker or others, identified and their location given?
- Can the reader tell from the report the relevance of each item of data that has been presented?
- Brevity: Effective writing is concise. Narrative recording should contain no unnecessary words or sentences. Lengthy run-on sentences only confuse the reader. Short declarative sentences convey information more efficiently.
- Separating Facts from Judgments: It is important that the Children’s Service Worker separate facts from judgments made about those facts. This separation encourages the worker to detail facts of the investigation before forming judgments. The facts should support the judgments rather than vice versa.
When forming and recording professional judgments, the Children’s Service Worker should be extremely cautious with “labeling” terms. The worker should avoid the use of psychological or medical diagnosis which he/she is not qualified to make when describing a condition/behavior.
- Timeliness: Timeliness in recording information is important for two major reasons:
- The sooner the information is recorded, the more accurate it is likely to be;
- For information to be introduced as evidence in a court hearing, records must:
- Be made during the regular course of the investigation;
- Be made at or near the time the event(s) occurred; and
- Be recorded by someone who has knowledge of the event(s).
- Discussions with the Division of Legal Services: Discussions with the Division of Legal Services (DLS), including the name of the DLS attorney, dates of discussion or options discussed, should not be documented in the record as this waives the right to attorney/client privilege. Rather, the narrative should reflect the decision reached by the Children’s Service Worker after discussions with DLS. If there would normally be an entry in the narrative concerning social work activity following a discussion with DLS, that entry may indicate a contact with DLS, but must not be specific with regards to content or options/recommendations discussed.
If the Children’s Service Worker desires to retain the content of the entire discussion, this information should be retained in a separate file in the circuit manager or supervisor’s office. Information retained in a separate place is not subject to release or subpoena.
1.3.3 Policy Requirements Related to Narrative Recording
For consistency throughout the state, narrative recording must, at a minimum, follow the guidelines and format described in this section. Exceptions to these methods require supervisory approval and will be limited to rare situations.
Case contacts and activities shall be summarized in the case narrative:
- At the conclusion of the assessment process in the form of an opening summary;
- At least monthly;
- Upon transferring an open case to another worker or county;
- At the conclusion of the treatment plan; and
- At closing of services to family.
More frequent entries may be utilized if warranted.
To ensure legibility and a business-like appearance, all case narratives shall be typed. Case narrative entries are to be signed and dated by the worker as indication that narrative entries are accurate.
Information referring to unsubstantiated CA/N investigations shall not be included in the family record.
Unsubstantiated reports and family assessments (when a family is not opened for services) should be filed so that staff can quickly access the record.
Unsubstantiated reports are retained in the county that completed the investigation. The county completing the investigation will receive the expungement list for the unsubstantiated report. Unsubstantiated reports are not transferred to another county with open family records.
The date of expungement, if unsubstantiated, must be noted at the time investigation is completed if there will be no record opened as a result of the investigation.