- What do I do if I misplace a client record in a public place?
- Can I use personal devices to write client records?
- What if I do not have time to complete a record?
Introduction
A fundamental part of good social work practice is maintaining and safely managing accurate, timely and objective records of your interactions with clients. Social work records support good social work practice. They help identify the risks and protective factors in a person’s life, and the support required. Records also promote continuity of care and communication with other agencies. They provide accountability to your clients and your organisation, and can be used as evidence for complaints, investigations, and in court.
This guidance note provides advice about maintaining professional standards of integrity and conduct, in relation to social work records.
Notifications
The SWRB receives notifications about issues relating to the completion of, storage of and accessing of social work records. Notifications may take the form of complaints or concerns raised by members of the public, people receiving social work services, employers or colleagues. These include the following situations:
- not completing required documentation in a timely manner
- not capturing full and complete information in assessments
- not identifying risks in key assessments
- leaving confidential client records in private homes or vehicles, where they could be viewed by others
- using personal devices, rather than work devices, to write client records
- accessing social work records about an individual without a work-related reason
- using social work records for personal purposes, for example for a personal Court application.
The SWRB Code of Conduct
The Code sets out the minimum professional standards of integrity and conduct that apply to social workers and to the social work profession. The following are relevant to social work records:
Principle 7: Respect the client’s privacy and confidentiality.
- Treat information gained in the course of the social worker/client relationship as confidential information and use it for professional purposes only.
- Store client records securely and make sure these are only accessed or removed from their secure place for social work or professional purposes.
- Use technology with diligence and care to protect client privacy.
It is important to respect a client’s right to privacy and the confidentiality of information provided during the professional relationship. Before disclosing information without your client’s consent, you should always consult with senior colleagues and other appropriate professionals, including seeking legal advice.
You should not use information collected in your role as a social worker for personal reasons., Similarly, you should not access information from your organisation’s files for anyone who is not your client. Records must only be used for purpose intended when the information was collected.
Information should be stored securely. If you accidentally misplace a client record or it is stolen, tell your supervisor or manager as soon as possible.
Principle 10: Keep accurate records and use technology effectively and safely.
- Keep clear and accurate records.
- Make records at the same time the events being recorded or as soon as possible afterwards and clearly attribute them to yourself.
- Do not tamper with original records in any way.
- Take special care to protect client privacy and client information when using technology and/or electronic records.
Accurate documentation of practice decisions and interventions provides a clear record of the nature of social work involvement with clients and progress in achieving established goals. These records also support the continuity of services to a client if they are transferred to another professional. While social workers are often under considerable time pressure, records must be completed as soon as possible after the event so that colleagues are aware of the current situation in the event of an emergency.
Accurate and timely record keeping plays a part in any complaints procedure. It not only protects clients, but also protects you as a social worker.
SWRB’s Core Competence Standards
In addition to the principles of the Code, the Core Competence Standards specifically mention record keeping in Standard 9: Competence to practice within legal and ethical boundaries of the social work profession. Under this standard, social workers are expected to:
- uphold the right to privacy and confidentiality of personal information and inform clients of the situations where the information may need to be disclosed;
- keep clear and accurate records and ensure these records are made at the same time as the events being recorded or as soon as possible afterwards.
Reflections
You may like to reflect on the following questions during supervision:
- How do I make time in my working day/week to record my interactions with clients promptly?
- What steps am I taking to make sure my social work records are secure at all times?
- How am I capturing key decisions and risks in my records?
- Am I aware of and following my organisation’s policy on record keeping?
- How am I ensuring that I’m using client information for the purposes that were intended when the information was collected?
- Am I aware of what is defined as a record under Section 4 the Public Records Act 2005?
Summary
The Code outlines the expectations that all social workers keep clear and accurate records of their interactions with clients. It expects that records are timely, always held securely and only used for professional purposes. Meeting these expectations can be difficult, given the many requirements placed on social workers. However, maintaining accurate and timely records promotes good social work practice and accountability to those you’re working with., This protects both your clients and you as a social worker.
Related Advice
- Social Workers Registration Board Ngā Ture Whanonga/Code of Conduct
- ANZASW Code of Ethics: Manaakitanga Principle
- ANZASW Practice Standards (Standard 7)
- Oranga Tamariki Practice Centre Guidance on case recording
- Public Records Act 2005
- Privacy Act 2020
- Health and Disability Commissioner’s (Code of Health and Disability Services Consumers’ Rights) Regulations 1996
- Health Information Privacy Code 2020.