Clinical record keeping is fundamental to the work of RSWs and standards of practice detail the content, format and maintenance requirements for the social work record. Please consult your regulatory organization’s standards of practice for specific requirements that apply to you.
Generally, records must:
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be systematic, dated, legible, current and accurate
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provide accountability for, and evidence of, services
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support continuity of care
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describe a client’s situation succinctly yet contain only information that is needed for care
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be impartial, objective and identify sources of data(e.g. opinions must be identified as such)
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be created as soon as possible (within the parameters of the client’s situation)
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enable the evaluation of service quality
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provide information to be used for research and education.
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adhere to applicable privacy and other legislation.
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include consents and authorizations
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outline fees charged and administered
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