Documentation

In training and in supervision you hear “if it isn’t written, it didn’t happen”.  This is true in a legal sense.  You may have observed visits with a child and parent, and the parent was not interacting well with the child.  If the observation was not detailed in a FSFN note objectively without bias then negative consequences could occur.  Direct observations are critical in determining a permanency plan for the child and must be documented. 

Every event that occurs while working with a family or on their case must be documented in FSFN:

  • All contacts with parents, caregivers, family, service providers, the child, attorney and other parties related to the case, whether on the phone, face to face, fax, email, etc.  All contacts must be documented in your notes in FSFN within 48 hours of the contact
  • All progress notes must accurately reflect the services and the conversations that were provided.  Report the FACTS clearly and concisely.  All contact must be documented objectively, using facts, direct statements, observable behaviors etc.  Conversations should be quoted when possible.  Professional conclusions, opinions or analysis must be labeled as such and attributed to the person making them.
  • All activities that you do such as sending or receiving documents, observations, interactions etc. on a case must be documented.
  • Whenever you are closing or transferring a case you must ensure that FSFN notes are up-to-date at the time of closure or transfer.
  •  All notes should include who, what, why (when possible), when, where, and how.  They should tell a complete objective story.  Case Manager should ensure that:

ü  All data entry fields in FSFN are completed.

ü  Notes state where the contact occurred.  Ensure the address is documented in the note.

ü  List who was contacted.  For service providers and any person not in the FSFN case, supply the full name, telephone number, address and other information that is pertinent.

Remember:

  • Someone else will have to read and understand your notes.
  • Files will be audited and must contain complete details of services provided.
  • The file and you may be subpoenaed for Court or trials.  It is important to have clear documentation (evidence) and not rely on your memory.
  • The longer the lapse in time between and event and note completion, the less accurate the details.
  • Avoid terms that show judgment

Terms to avoid:

Properly: rather, explain in behavioral terms what is meant by “proper”.

Appropriate/inappropriate: rather, describe the client behaviors necessary to reduce risk.

Adequate/inadequate: rather, state specifics of what is meant

Suitable: subject to interpretation; state the specifics.

Stable: What is meant by “stable employment”?  A 15 hour a week job?  A 40 hour a week job for 3 months?

A.S.A.P.:   is not a time frame.  Do you mean 7 days or overnight?  State that.

Ongoing: is not a time frame.  Instead, choose a date or specific date range.  Since when?

Successful Completion: Changing behavior is more than completing a program.  Define the behavioral changes that will occur as a result of completion

Currently: since when? How long?

It has been reported:  who is reporting?

Appears: impression of being…not concrete or sure

Give yourself credit for all the hard work and services you provide.

Document everything you do in FSFN.