Pitfalls for practitioners 3

Facts and professional judgements are not distinguished in the record

Social work involves collecting information and making assessments and professional judgements. Practitioners gather information and observations, their own and those of others, and use a mixture of research, experience and theory to analyse this information. Consequently, a significant percentage of what is recorded in social work files are opinions of social workers and others (1).

Research studies which have reviewed social work records have noted that observed and verified facts are very often not differentiated from opinions (2). Facts and opinions are interwoven throughout the file and appear to be given equal weight and status (3).

Opinions are recorded as fact

One or more professionals, or indeed family members, presenting a strong opinion about an individual or situation can result in their opinion being recorded in the file as a fact. Particularly where the information received is consistent with the observations of the social worker (4).

Opinions are not substantiated

Recording under pressure of time or space can result in only opinions being recorded, like a professional short hand. However, the absence of supporting information means that colleagues and supervisors cannot follow or test the conclusions arrived at.

Facts and opinions are not differentiated

Failing to differentiate between fact and opinion can result in the significance of some information being overlooked, or opinions becoming accepted as facts and unduly influencing the management of the case (5).

Views established at an early stage can influence the way in which practitioners sift and sort information and how and what they record (6).

If opinions and judgements are not substantiated in the record it can be difficult to explain how these were made to family members who access the record, particularly if the practitioner who wrote them is no longer working within the agency (7).

Only facts are recorded

It is also important that records are not simply confined to factual information. A common criticism of social work records is that there is an absence of analysis. A lack of analysis can result in records that focus on description. They record what is happening, but do not move beyond this to consider why it is happening. Any analysis takes place outside of the record in the mind of the practitioner (8). Consequently, the rationale underpinning decision-making is not open to families who access their record (9).

Records should therefore contain both facts and opinions. However, opinions should be distinguished from facts and substantiated. The reasons for actions and decisions should be clearly recorded so that they are available to the service user and agency.

Avoid the pitfall

• An easy way to avoid this pitfall is to share records with families. Research has shown that practitioners substantiate opinions more clearly if they know that the family will be seeing what they have recorded (10).
• Separate facts and opinions in your recording. Record the facts first and then record your analysis of them. Remember to include any research evidence you have used.
• Where another professional or family member gives an opinion, ensure that this is recorded as such.

Activity

Try Recording Skills Exercise 4: Fact or Professional Judgement.

Use Audit Sheet 3 (Microsoft Word format) to review your files

References

1. Monnickendam M, Yaniv H and Geva, N (1984) Practitioners and the Case Record: Patterns of Use. Administration in Social Work 18: 73-87. Kagle J D (1993) Record Keeping for the 1990s. Social Work  38: 190 196. Ames N (1999) Social Work Recording: A New Look at an Old Issue. Journal of Social Work Education  35: 227-236. Prince K (1996) Boring Records? Communication Speech and Writing in Social Work. Jessica Kingsley, London.

2. Monnickendam M, Yaniv H and Geva, N (1984) Practitioners and the Case Record: Patterns of Use. Administration in Social Work 18: 73-87. Kagle J D (1993) Record Keeping for the 1990s. Social Work  38: 190 196. Ames N (1999) Social Work Recording: A New Look at an Old Issue. Journal of Social Work Education  35: 227-236. Prince K (1996) Boring Records? Communication Speech and Writing in Social Work. Jessica Kingsley, London.

3. Monnickendam M, Yaniv H and Geva, N (1984) Practitioners and the Case Record: Patterns of Use. Administration in Social Work 18: 73-87. Kagle J D (1993) Record Keeping for the 1990s. Social Work  38: 190 196. Ames N (1999) Social Work Recording: A New Look at an Old Issue. Journal of Social Work Education  35: 227-236. Prince K (1996) Boring Records? Communication Speech and Writing in Social Work. Jessica Kingsley, London.

4. Department of Health (1991) Child Abuse: A Study of Inquiry Reports 1980 – 1989. HMSO, London.

5. Department of Health (1991) Child Abuse: A Study of Inquiry Reports 1980 – 1989. HMSO, London. Ovreveit J (1986) Improving Social Work Records and Practice. BASW, Birmingham

6. Ovreveit J (1986) Improving Social Work Records and Practice. BASW, Birmingham. Prince K (1996) Boring Records? Communication Speech and Writing in Social Work. Jessica Kingsley, London

7. Monnickendam M, Yaniv H and Geva, N (1984) Practitioners and the Case Record: Patterns of Use. Administration in Social Work 18: 73-87. Kagle J D (1993) Record Keeping for the 1990s. Social Work  38: 190 196. Ames N (1999) Social Work Recording: A New Look at an Old Issue. Journal of Social Work Education  35: 227-236. Ovreveit J (1986) Improving Social Work Records and Practice. BASW, Birmingham.

8. Monnickendam M, Yaniv H and Geva, N (1984) Practitioners and the Case Record: Patterns of Use. Administration in Social Work 18: 73-87.

9. Ovreveit J (1986) Improving Social Work Records and Practice. BASW, Birmingham. Prince K (1996) Boring Records? Communication Speech and Writing in Social Work. Jessica Kingsley, London.

10. Ovreveit J (1986) Improving Social Work Records and Practice. BASW, Birmingham. Prince K (1996) Boring Records? Communication Speech and Writing in Social Work. Jessica Kingsley, London.