Tips on How to Document Like a BOSS!
Everyone’s documentation style is different, and as mental health professionals, we are all trained differently on how to ethically document based on the settings we’ve worked.
This formula is not a ‘one size fits all,’ but I think it sets the groundwork for what you should be thinking about when you document your interactions with students and families.
The writer’s eyes are not the only ones viewing the record of your student/client. Before you write, think about the people who may access this document in the future (both expected and unexpected).
What would the next assigned mental health professional appreciate reading about this particular client/student case? What’s important for them to know?
Documentation is a responsibility and a privilege. Not only do our students/clients deserve our full attention and competency, but they also deserve intentionality when writing their stories. Consider following these principles:
Keep the foundation’s values and ethics as the basis for your writing. What are your profession’s values and ethical code? Client self-determination and confidentiality should be evident in your writing.
Words matter, and how you speak about clients and to clients should reflect respect for human dignity.
Be sure to include strengths-based descriptors.
Make sure that the client’s record is physically secure. Thankfully, SocialNote is 100% electronically secure, so you don’t have to deal with paper or post-it notes. But, if you do, you want to ensure that your desk, filing cabinet, or storage area is locked.
Be sure you have a signed informed consent on file for the client/student you are working with. If the person is a minor, consent from a parent or legal guardian is necessary.
Consider your agency/school documentation requirements. When I worked there, my school did not have a documentation policy, so I had to rely on my clinical supervisor and licensing board policy to inform my documentation practices.
Understand when you should be documenting. If you’re a social worker, look at the NASW Code of Ethics, Section 304.
Know what to document and what not to document. This is one of the greatest challenges as a mental health professional. My philosophy is that records should be concise to protect the client’s privacy, and there are times when they must include more information to ensure service delivery, meet accountability standards and afford legal protection.
When creating SocialNote, we thought about all of these things. We wanted to ensure that you document easily, concisely, securely, and ethically. What other thoughts and ideas do you have about documentation? What are some things you do to ensure you’re staying up to date on all the ethics of documentation? Share below.