Reviews of client records
Reviewing a sample of
client records can help guide training in many ways. Several examples include:
- Identifying areas in which practice differs from intended procedure;
- Identifying problems in common practice such as failure to refer or document when appropriate;
- Grounding training in the knowledge of what employees are already doing well;
- Providing scenarios or case studies to make training interactive and relevant;
- Identifying frequently encountered challenging situations, types of clients, or obstacles to implementing intended procedures.
Several examples when client records may become important include:
(1) A State has received a co-occurring disorders initiative and intends to develop training for counselors in both mental health and addiction treatment systems on integrated treatment. The State also wishes to identify problem areas to address. One of its first steps is a chart review to determine how often clients are screened for the “other” disorder (for example, screening for mental disorders by an addiction treatment counselor), how often they are referred for treatment, and how often there is follow-up to determine whether treatment is being provided.
(2) A team of consultants has been asked to help a provider organization plan to address nicotine addiction as part of its treatment program. On a site visit, to help lay the groundwork for staff training, the team reviews sample chart to see if nicotine addiction is currently being flagged as an issue by treatment providers.
For other resources on client records, see the following:
- Client Records: Keep or Toss? – this article explores one of the thornier issues of social work today that involves the why, when, and where of keeping clinical records.
- Electronic Records Express is an initiative by State Disability Determination Services (DDS) and Social Security to increase the use of electronic options for submitting records related to disability claims.
- Client Records as an Ethical Issue is an article by Jim Jensen on Treatment Planning in the current issue of The Addiction Professional includes important information for all addiction professionals and it relates ethical standards.
- Client Record and Professional Liability is a training video for purchase that shows you the risks you take when you fail to keep complete and accurate records and how to avoid those risks. It is available through NASW Press, which is a leading scholarly press in the social sciences. It serves faculty, practitioners, agencies, libraries, clinicians, and researchers throughout the United States and abroad.
- How long to keep client records – The Home for Little Wanders provides background and guidance on how long to keep records for adoptions.
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