have questions and concerns about the documentation they are required to complete in their agency. This article will discuss three important documentation considerations to discuss during supervision.
Agency Policy: Supervisors should first seek to understand the documentation policies of the agency where their supervisee is employed. Often agencies are required to document their work with clients following guidelines set forth by their accrediting/credentialing body. In addition to needing to meet the requirements of accrediting/credentialing entities, if a Social Worker is employed by an agency that receives payment for services from a third party (such as private practice counseling agencies who receive payment from health insurance) documentation frequently has to contain specific items in order for payment to be received. A supervisor should rarely encourage a Social Worker to go against their agency policy and/or third party requirements as this could result in disciplinary action or even job loss. If a Social Worker is working for an agency without documentation standards, a worker should be encouraged to help their agency draft standards that ensure documentation is completed in a uniform, thorough, and ethical manner. Legal/Ethical Requirements: While in theory agency/third party documentation requirements should rarely pose any legal or ethical risk to a Social Worker, if such a risks should arise, Supervisors should attempt to help their supervisees resolve the issue. Supervisors should encourage the supervisee resolve the issue or concern with the agency. If a resolution with the agency is unable to be reached the supervisor should assist the supervisee to contact the appropriate state ethical boards to ensure that risk to the supervisee has been mitigated. In situations of this nature it is important for the supervisor and the supervisee to ensure that they protect their license first and foremost.
Less or More? There are two different schools of thought related to documentation: Less is More; and More is More.
Less is More, is usually motivated by a worker’s desire to protect themselves and the agency. If a piece of documentation were to be called into question if a document says only the bare minimum there is less risk of any adverse reaction befalling the worker or the agency based on the documentation. The downside of this school of thought, is that it can be difficult for colleagues or future workers to pick up where the prior Social Worker left off if the documentation is so vague as to be unhelpful.
For Social Workers who believe in More is More usually feel that if they do not document something completely it either didn’t happen, or they may not remember that something happened. Documenting this way can be very important for Social Workers with large caseloads. However, if documentation using this school of thought were to be questioned in a court of law the more a piece of documentation says, the more there is to question.
In order to help their supervisees ensure their documentation meets all requirements, and also contains the amount of information the supervisee is comfortable with, supervisors should ask to see several examples of their documentation (with all identifying client information removed).
In conclusion, supervisors should encourage those they supervise to follow agency policy unless doing so poses a legal or ethical risk. The answer to less versus more documentation usually can be resolved by understanding the documentation requirements of the agency, the credentialing body, and the documentation preferences of the individual worker.
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