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Social Work Documentation, 2nd Edition
A Guide to Strengthening Your Case Recording
Nancy L. Sidell
ISBN: 978-0-87101-486-3. 2015. Item #4863. 236 pages.
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The second edition of Social Work Documentation: A Guide to Strengthening Your Case Recording is an update to Nancy L. Sidell's 2011 book on the importance of developing effective social work documentation skills. The new edition aims to help practitioners build writing skills in a variety of settings. New materials include updates on current practice issues such as electronic case recording and trauma-informed documentation. The book addresses the need for learning to keep effective documentation with new exercises and provides tips for assessing and documenting client cultural differences of relevance. Sidell encourages individuals to reflect on personal strengths and challenges related to documentation skills. Social Work Documentation is a how-to guide for social work students and practitioners interested in good record keeping and improving their documentation skills.
About the Author
About This Book

Part I: Understanding Documentation

Chapter 1: Introduction to Social Work Documentation

Chapter 2: Documentation Today

Chapter 3: Laying the Foundation

Chapter 4: Special Issues in Documentation

Part II: Sections of a Case Record

Chapter 5: Information Summary Sheets

Chapter 6: Confidentiality, Release Forms, and Informed Consent Forms

Chapter 7: Assessments and Treatment Plans

Chapter 8: Documenting Client Progress

Chapter 9: Communication with and about Clients

Part III: Beyond the Basics

Chapter 10: Getting and Giving Feedback

Chapter 11: Supervision and Documentation

Chapter 12: The Future of Documentation

The purpose of this book is to provide practical, hands-on experience to social workers wishing to improve their documentation skills. It stems from concerns about the wearing away of basic writing skills, hastened by a reduced emphasis on grammar and spelling at all levels of education and a devaluation of the written word. One example of this erosion is the appearance in formal kinds of writing of shorthand abbreviations, previously acceptable only in informal electronic communications.

Social workers must document the services they provide, regardless of their educational level or the setting in which they are employed. Many are unprepared for this responsibility. Social work programs teach skills necessary for effective social work practice but often leave instruction about professional documentation to agency field instructors. Social workers should arrive at the workplace well prepared to document, but often they do not, and most agencies hiring new social workers must train them on the job.

Undergraduate and graduate students, as well as seasoned social workers, can benefit from instruction in the basics of social work documentation. This book is written with the goal of improving social workers’ writing skills and better preparing them for the written demands of their work. It can be useful as a reference tool in agency settings where employees need assistance with documentation concepts.

This book reviews common formats and examples. It cannot, however, cover all of the documentation requirements that social workers may find during their careers or all of the settings in which social workers practice. The term "agency" is most commonly used to refer to the workplace throughout this book for efficiency purposes and in no way conveys the richness of the numerous settings in which social workers are employed. Neither does this book replace specific agency guidelines or jurisdictional rulings. Not all examples will be useful in every setting, given the wide variation in documentation requirements. But although this book cannot replace agency policy documents or supervisory guidance, it can serve as a learning tool.

The book is divided into three sections. The first four chapters give a general overview of documentation - its history, considerations that need to be addressed before documentation begins, and special issues. The second portion of the book reviews in turn the different components of a typical case file. The last section focuses on ways in which documentation can be evaluated and improved. Continuous skill improvement and supervisory issues are covered here, along with a look at future trends and directions. Over 120 exercises are found throughout the book, designed to build confidence about and knowledge of important aspects of documentation.

The exercises are designed to elicit written answers, which can be kept in a separate notebook or folder. Many of them are best completed with one or more peers who work through the exercises at the same time. Although the term "peer" is used throughout the exercises, a supervisor, fellow student, or colleague can fill this role. For example, a social worker may find that a supervisor’s feedback about the exercises is helpful to his or her professional growth. Alternatively, working with a peer who is also interested in improving documenting skills may be beneficial. Both social workers can work through the exercises and provide one another with helpful feedback. Specific and constructive feedback from a supervisor or peer can promote more polished and professional recording abilities. These skills will greatly enhance a social worker’s professionalism and ultimately result in better service to clients.
Nancy L. Sidell, PhD, is professor of social work at Mansfield University, Mansfield, Pennsylvania. She has served as BSW program director and department chair during her tenure at Mansfield University. Sidell has over 18 years of practice experience as a social worker in health, mental health, and nursing home settings. She is an item development consultant with the Association of Social Work Boards and a coauthor (with Denise K. Smiley) of Professional Communication Skills in Social Work. She has also authored numerous journal articles. She lives in Wellsboro, Pennsylvania, and enjoys quilting, road biking, and hiking.
Dr. Sidell provides a comprehensive rationale as to why documentation is important to social work professionals, the agencies providing assistance, and the clients that are recipients of the services. Expertly detailed and increased in the second edition are case examples from a variety of practice settings. The highlights of ethical, technological, and supervisory scenarios are essential and timely. Written from a strengths perspective, the book is filled with a treasure trove of information and belongs on the desk of every social worker from undergraduate student to seasoned professional.

Pamela A. Richmond, PhD
Associate Professor of Social Work
Colorado State University-Pueblo
Social Work Documentation, 2nd Edition was reviewed by Caprecia A. Miller for the journal Social Work.

Documentation is a critical part of the social work profession. Social workers, interns, and practitioners should not underestimate the importance of client documentation and case recording. Sidell’s book captures, from the beginning of social work era to current day, the significance and criticality of the most important aspect of the profession. Sidell acknowledges that although documentation is time consuming, tedious, and reduces client interaction and involvement, it is needed for client evaluation and assessment of service, continuity of service, and frequently reimbursement. The book discusses poor documentation—or lack thereof—and the impact it has on the client. An important phrase known to the world of social workers, “if it’s not documented, it’s not done,” serves as a constant reminder and is perhaps the mantra to the profession. It is also important for social workers to know that throughout the client session there could potentially be sensitive or personal information shared by the client that should never be documented to prevent from embarrassing the client and being misinterpreted by others. In most of cases, such personal information has no bearing on the services. The author ensures that the reader understands what to document, what not to document, when to write more, and when to write less. Sidell’s book outlines the basics for any new social worker, intern, or practitioner.

Read the full review. Available to subscribers of Social Work.
Earn 7.0 CEUs for reading this title! For more information, visit the Social Work Online CE Institute.