This post was written by guest author Rhashida Brown.
I am a family social worker and I write to document my clients’ progression and regression.
I write treatment plans, which consist of goals that I empower my clients to achieve, as we collaboratively work together. If these goals are not met, I write revisions on a quarterly basis. Revisions will include amending goals to meet the client’s needs or completely eliminating the goal if the client feels the goal is not attainable or no longer wants to complete it.
I write progress notes on my clients to keep a paper trail for agency records of our daily interactions. I write collateral notes discussing interactions I have with any of my client’s outside providers, such as therapists, counselors, primary physicians, staff from substance use treatment programs, and anyone who actively works with the client.
On a weekly basis, I write clinical notes on some of the group workshops that I facilitate at the agency.
Many of these groups are girl groups for the youth in the facility and relapse prevention groups. I write incident reports when a major issue has taken place with a client and I email these reports to anyone who is working with the client. I write to update clients’ charts with their current medications, whether it’s psychotropic medicine or medicine for their physical health—this information must be updated in their charts. I write to obtain consent release to speak to my clients’ other providers. I also write letters or emails to advocate on behalf of my clients, if my support is needed.
A large portion of my job consists of documentation, and that is across the board with any agency I have ever worked with. Overall, documentation is very important in the field of social work. It is crucial to keep a paper trail to cover yourself and the agency. You always want to make sure you dot your i’s and cross your t’s.