Pitfalls for practitioners 7

The record is not used as a tool for analysis

There has been a significant change in the nature of case recording, which in many ways reflects the wider changes in social work. Staffing levels, increased user involvement and increased accountability to service users, the organisation and profession, are all factors which have influenced the development of the case record and recording practice (1).

The traditional case record reflected the interaction between the practitioner and the service user, in the context of the service user's history and current situation. At its heart was the relationship between the practitioner and service user. Traditional case records were 'often written in an abstract discursive style for a sophisticated professional audience' (2) within the agency. Practitioners were reluctant to restrict their professional autonomy by establishing 'clear and specific criteria for the clinical (practice) record' (3).

In the absence of any definition by practitioners, the way in which the case record developed to meet the changes in legislation and social work practice was led by organisational and managerial requirements (4). Whilst, the shift to more structured, focused and evidenced recording has been both welcome and necessary, concerns have been expressed that using case recording simply to evidence individual and organisational accountability neglects it's value as a practice tool (5).

'The case file is the single most important tool available to social workers and their managers when making decisions as to how best to safeguard the welfare of children under their care. It should clearly and accessibly record the available information about the child and the action that has been taken on the case to date. Reference to the case file should be made at every stage of the case and before any significant decision is made'. (6)

The case record should be more than a complex diary of the practitioner's actions and the response of the service user. To use it in such a way is like buying a video recorder and then only using its clock to tell the time. Practitioners should use case recording to support analysis and reflection (7).

Using recording for analysis requires practitioners to assess the weight that should be given to information gathered. To do this practitioners should draw on their knowledge from research and practice combined with an understanding of the child's needs within his or her family and/or the context in which the child lives (8).

Analysis provides a clear direction to ongoing records and assists practitioners in identifying what information should be recorded (9). However analysis often takes place outside day to day recording and is facilitated by specific formats. Initial and Core Assessments, genograms, ecomaps, social histories and case summaries are all examples of formats that support analysis. They require practitioners to organise, manipulate and evaluate the information gathered in the case files. They provide an opportunity to assess the child's needs, monitor progress, evaluate the effectiveness of interventions, and to identify patterns that would may not immediately be apparent.

Often case recording can become almost a subconscious activity, like driving a car along a familiar road. You arrive but can't say exactly how you got there. The regular use of tools for analysis in the case record keeps recording a proactive activity that supports ongoing assessment, planning and intervention.

Avoid the pitfall

Audit sheet

Use Audit Sheet 7 (Microsoft Word format).

References

1. Kagle J D (1984) Restoring the Clinical Record. Social Work. 19: 46-50. 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: 228. Prince K (1996) Boring Records? Communication Speech and Writing in Social Work, London, Jessica Kingsley.

2. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190 -196.

3. Kagle, J.D. (1984) Restoring the Clinical Record, Social Work, 19, p46.

4. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190 196. Kagle, J D (1995) Recording. in Edwards R L (Editor in Chief) Encyclopaedia of Social Work (19th Edition). NASW, Washington,

5. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190 196.

6. Laming (2003) The Victoria Climbie Inquiry Report HMSO, London. p209

7. DeRoos Y S (1990) The development of practice wisdom through human problem solving processes. Social Services Review 64:276-289. Kagle J D (1993) Record Keeping for the 1990s. Social Work 38: 190 196.

8. Department of Health et al (2000) Framework for the Assessment of Children in Need and their Families. The Stationary Office, London.

9. 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. Shemmings D (1991) Client Access to Records: Participation in Social Work. Avebury/Gower, Aldershot.