Raising the Titanic: Rescuing Social Work Documentation from the Sea of Ethical Risk

Abstract

One of the most contentious issues in social work practice concerns what should be written about people who access social work services, how comprehensively, and in what format social work assessments, interventions and outcomes should be documented. The present paper describes a structured approach linked to an action research project that was undertaken by hospital social workers to identify and minimise problems associated with documentation in the medical record. The social work ethics audit provided social work staff with a risk management tool that highlighted documentation as a key area of ethical risk. Through a process of evaluation existing recording practices, social workers were able to meet the challenge of improving social work recording in medical records, returning it to its proper place as a vital component of clinical and ethical practice rather than as an administrative task submerged beneath competing priorities. It was anticipated that the social work documentation proforma that resulted from the ethics audit process would have applicability in other health care settings.