This month’s ASWB LMSW and LCSW topic is one that is important well beyond the exam: Clinical Documentation. Even our code of ethics speaks to the importance of clinical documentation. “Social workers should take reasonable steps to ensure that documentation in records is accurate and reflects the services provided. Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future” (standard 3.04, NASW Code of Ethics).
Regardless of the setting(s) you work in throughout your career, clinical documentation will be a part of your job. Therefore, today’s blog gives an introduction to the purposes of clinical documentation and considerations for clinical documentation. It doesn't have to be as daunting as we sometimes imagine it to be.
Clinical Documentation Purposes
When working with clients, documentation of services provided is of the utmost importance. It serves a variety of functions. While this isn’t an exhaustive list, here are a few functions clinical documentation serves:
- Gives evidence of the services provided.
- Plans for the treatment and care of clients.
- Notes the progress being made toward goals.
- Allows for clear and concise communication amongst team members when working in a team setting.
- Helps ensure continuity of care if the social worker is unable to continue services (due to disability, death, serious illness, etc.).
- Legal purposes: If there is no record of something occurring, according to the law, it may not have occurred at all. Should we find ourselves in a sticky legal situation, accurate and concise documentation can be protective for us.
Clinical Documentation Considerations
We always want to keep two things in mind:
1. Our records can be subpoenaed.
2. Our clients can request to see a copy of their records. For instance, we do not want to put anything in our documentation that we wouldn't want our client to see. We must balance the need to provide accurate information, while also protecting our client's confidentiality. We want to document what we need to in order to provide effective services and protect ourselves legally and ethically.
If you’re ever unsure of what or how to effectively document a particular client scenario, there is a clear answer: to seek supervision. On the exam if it tells us the social worker is unsure of what to do, we should seek supervision. And if it’s real life and we’re unsure of what to do, we should take that very same step.
ASWB Clinical Documentation Practice Question
A social worker meets with a client who inquires what kind of notes the social worker keeps in their file. They express concern that they don’t want what they share in session to be available for anyone else to see. What should the social worker do FIRST?
A. Honor the client’s self determination by not keeping a client file
B. Seek supervision to determine whether they can honor this request
C. Discuss what is and is not documented and the situations in which information may be shared
D. Ensure the client no one can review their file without their consent
(Scroll for answer and rationale)
The correct answer is C: To discuss what is and is not documented and the situations in which information may be shared. A is incorrect because legally and ethically we cannot simply do away with a client’s file.. We can honor their self determination by considering what is and is not documented. But eliminating documentation entirely is unwise. B is incorrect because there is no reason to consult with a supervisor at this time. If the question tells us that the social worker is unsure of how to proceed, then we seek supervision. D is incorrect because there are situations in which the file may be shared without their consent. (Specifically, if the court orders us to do so).
ASWB masters (LMSW) and clinical (LCSW) exam preparation
Are you ready for clinical documentation questions you may see on your exam? How about for your real practice? TDC’s LMSW and LCSW exam prep programs give you everything you need to successfully answer exam questions on this topic. And if you’re ever unsure about something as you’re studying, good news! Every one of our programs comes with access to coaching. You can reach out to your coach via email with any questions as you go through your program. Your coach will promptly get back to you with a personalized response.
Already licensed? TDC continues to expand its continuing education library to cover a variety of topics relevant to your clinical practice. Just like our exam prep, it’s about more than checking off licensure requirements. Each CE is engaging and will leave you with practical clinical knowledge to apply to your practice.