- What do I do if I misplace a client record is a public place?
- Can I use personal devices to write client records?
- What if I do not have time to complete a record?
- What does the SWRB Code of Conduct say about social work records?
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 by helping to 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 those with whom you are working and your organisation, and can be used as evidence for complaints, investigations, and in court.
This guidance note provides regulatory advice about social work records. It provides examples of the types of notifications the Social Workers Registration Board (SWRB) receives, relating to social work records. There are also some questions to consider for further reflection on this topic.
The SWRB receives notifications about the completion of, storage of and accessing of social work records. These notifications may take the form of complaints or concerns raised by members of the public, people receiving social work services, employers or colleagues. This includes 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 whānau or friends, when not having a legitimate reason to do so
- using social work records for personal purposes, for example for a personal Court application.
The Code of Conduct
The SWRB Code of Conduct (the Code) sets out the minimum professional standards of integrity and conduct that apply to registered social workers and to the social work profession in general. The following principles are relevant to the topic of social work records:
Principle 7: Respect the client’s privacy and confidentiality.
- treating information gained in the course of the social worker/client relationship as confidential information and use it for professional purposes only
- storing client records securely and making sure these are only accessed or removed from their secure place for social work or professional purposes
- using technology with diligence and care to protect client privacy and take special precautions to protect client information in any electronic records, emails, documents, notes, or any other place where client information is held.
Principle 7 sets out the importance of respecting a client’s right to privacy and the confidentiality of information provided in the course of 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).
This principle includes not using information collected in your role as a social worker for personal reasons. It also includes not accessing information from your organisation’s files for anyone who is not your client. Records must not be used for purposes other than what was intended when the information was collected.
Information should be stored securely. If you accidentally misplace a client record in a public place, or it is stolen, tell your supervisor or manager, as soon as possible.
Principle 10: Keep accurate records and use technology effectively and safely.
- keeping clear and accurate records
- making these records at the same time the events being recorded or as soon as possible afterwards and clearly attribute them to yourself
- not tampering with original records in any way
- taking 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 being recorded so that colleagues are aware of the current situation in the event of an emergency.
You also need to be aware of the part that accurate and timely record keeping plays in any complaints procedure. Accurate recording 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 of conduct, the core competencies specifically mention record keeping in the context of 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.
Below are some questions, that you could consider using in supervision to reflect on the topic of social work records:
- How am I ensuring that I make time in my working day/week to record my interactions with clients in a timely way?
- What steps am I taking to make sure my social work records are appropriately 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 records?
- 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, for example text messages, images, and diary entries?
The SWRB Code of Conduct outlines the expectations that all social workers keep clear and accurate records of their interactions with clients. It expects that records are timely, are held securely at all times 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. Good record keeping not only protects your clients, but also protects you as a social worker if you are involved in a complaints procedure.
- 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.