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Third Edition

Jill Doner Kagle and Sandra Kopels

The latest edition of Social Work Records describes an approach to recordkeeping that is well-suited to contemporary practice. The authors encourage practitioners to seek a balance among accountability, supporting and improving practice, efficiency, and client privacy in selecting and organizing information in their records. They propose guidelines for improving agency-wide policies and procedures and include new material on demonstrating cultural competence, systematic assessment, managed care, computerization, and record security. The process of recording, as well as the record itself, are described and illustrated in ways that fit the realities of today’s practice.

Social Work Records is a single source that: introduces the 15 principles of good records and their usefulness to assess the quality, appropriateness, and impact of services; presents an overview of the content of social work records using the Service-Centered Record format; focuses on the structure of the record by describing and analyzing a wide range of approaches, formats, and forms that are used to select and organize information; offers solutions to issues in practice from both the direct-service and the administrative perspective; provides a thorough analysis of records and the law.

$29.95 list, 309 pages

10-digit ISBN: 1-57766-546-5

13-digit ISBN: 978-1-57766-546-5

© 2008

Table of Contents

Introduction

1. The Principles, Functions, and History of Records

Fifteen Principles of Good Records / A Brief History of Social Work Recording / Contemporary Issues / Recording and Professional Judgment

2. Service-Centered Recording

The Service-Centered Record / Elements of Content / What Should Be Excluded from Records

3. Records Used in Social Work Education

Process Recording / The Teaching/Learning (T/L) Record / Essential Recording / Improving Education for Recordkeeping

4. The Structure of Records I: Narrative and Other Clinical Records

Narrative Reports / The Problem-Oriented Record / Monitoring Movement / Goal Attainment Scaling

5. The Structure of Records II: Forms

Creating Forms / Examples of Forms

6. Practice Issues

The Quality of Records / Benefits of the Recording Process / Records That Clients Prepare / Recordkeeping in Private Practice / Records and Managed Care / Practice Guidelines

7. Administrative Issues

The Cost of Recordkeeping / The Security of Records / Computers and Records / Records in Research

8. Records and the Law

Basic Privacy Principles / A Brief History of Federal Privacy and Records Legislation / Important Federal Laws Related to Social Work Records / HIPAA and Its Relationship to State Laws / HIPAA, State Law, and the Records of Specific Client Populations

9. Records and the Courts

Why Records Would Be Used in Court / Subpoenas / Defining the Record under the Subpoena / Personal Notes / Privilege / Responses to Requests for Records / Retention of Records / Expungement of Records