Principle IV: The Social Work and Social Service Work Record

The creation and maintenance of records is an essential component of ethical and professional practice. The process of preparing and organizing material for the record facilitates the understanding of the client and client system and allows for the planning of appropriate interventions. The purpose of the social work and social service work record is to: 

• document services in a recognizable form; 
• ensure the continuity and quality of service; 
• establish accountability for and evidence of the services rendered; 
• enable the evaluation of service quality; and 
• provide information to be used for research and education. 

College registrants shall ensure that records are current, accurate, contain relevant information about clients and are managed in a manner that protects client privacy and in accordance with any applicable privacy and other legislation. 

INTERPRETATION

4.1 Record Content and Format

4.1.1 College registrants shall record information in a manner that conforms with accepted service or intervention standards and protocols within the profession, is relevant to the services provided, and is in a format that facilitates the monitoring and evaluation of the effects of the service/intervention. College registrants include all required information in the record (see footnote 1 for a list). 

4.1.2 Social work and social service work records shall include progress notes and reports and, depending on whether the practice context is direct/clinical or indirect/non-clinical, may include any or all of the following: 

• checklists; 
• correspondence; 
• minutes; 
• client reflections, journals, art, and/or homework (direct/clinical settings); 
• appointment records; and/or 
• audio and/or video recordings. 

The tools or data used by the College registrant in developing a professional opinion may be included in the record. Such tools or data may include rough or draft notes, messages, test results, sociograms and/or genograms. If placed in the record, these tools cannot be removed and shall be managed in the same way as other documents in the record, in accordance with privacy legislation; if not placed in the record, they shall be appropriately destroyed. 

4.1.3 College registrants shall keep accurate records. An accurate record shall: 

i) clearly document the client’s situation as they (or the client system) have described it; 

ii) contain only information that is useful to the understanding of the situation and the desired outcome; 

iii) report impartially and objectively the factors relevant to the client’s situation, and make a clear distinction between the College registrant’s observations and opinions and the information reported by the client; 

iv) be easy to understand, avoiding vague, unclear or obscure language and/or symbols; 

v) clearly identify corrections; 

vi) be free of bias, prejudice and/or discriminatory remarks; 

vii) identify sources of data; and 

viii) indicate the identity of the service provider.

4.1.4 College registrants shall not make a statement in the record, or in reports based on the record, or issue or sign a certificate, report or other documents in the course of practising either profession that the College registrant knows or ought reasonably to know is false, misleading, inaccurate or otherwise unprofessional.

4.1.5 College registrants shall keep systematic, dated, and legible records for each client or client system served.

4.1.6 College registrants shall ensure the record reflects the service provided and the identity, designation and/or title of the service provider. 

Social service work registrants shall use: 

• the designation “RSSW”; and/or 
• the title “Social Service Worker”; or 
• the title “Registered Social Service Worker”. 

Social work registrants shall use: 

• the designation “RSW”; and/or 
• the title “Social Worker”; or 
• the title “Registered Social Worker”. 

Principle VII: Advertising and Communications describes the requirements for College registrants holding an earned doctorate in social work who wish to use the title “doctor”.

4.1.7 College registrants shall document their own actions and shall not sign records or reports authored by any other person, except in accordance with Interpretation 4.1.8 or 4.1.9 .

4.1.8 A College registrant may sign a record or report authored by another person, but only where the College registrant co-signs that record or report, together with the author, in one of the following situations: 

(i) in the College registrant’s capacity as a supervisor of the author of the record or report; or 

(ii) in the College registrant’s capacity as an authorized signing officer of a professional corporation, where the author of the record or report is an employee, shareholder, officer or director of that professional corporation; or 

(iii) in the College registrant’s capacity as a member of a multi-disciplinary team that participated in providing the observations and recommendations contained in the record or report, where the author of the record or report is also a member of that multi-disciplinary team.

4.1.9 A College registrant may sign a record or report authored by another person where the author is unable to sign the record or report due to illness, disability, absence or other good cause, but only if the content of the record or report is within the College registrant’s scope of practice, and: 

i) the author expressly authorizes the College registrant, either verbally or in writing, to sign the record or report on the author’s behalf; or, if such authorization is not reasonably available, the registrant takes steps to ensure the currency and accuracy of the information and recommendations contained in the record or report; and 

ii) the College registrant clearly indicates the capacity in which they are signing the record or report.

4.1.10 In situations in which the College registrant signs the record or report with the author’s authorization, they are simply signing on behalf of the author and not endorsing the currency and accuracy of the information and recommendations in the record or report. In such cases, the College registrant shall sign the author’s name (in quotation marks), followed by the registrant’s name, and indicate that they are signing the record or report on behalf of the author, as follows: 

[“author’s name”] by [College registrant’s name], on behalf of [author’s name].

4.1.11 Where authorization is not reasonably available and the College registrant has taken steps to ensure the currency and accuracy of the information and recommendations contained in the record or report, the College registrant shall sign their own name to the record or report. In so doing, the College registrant is endorsing the currency and accuracy of the information and recommendations in the record or report, and the College registrant shall not sign the record if they cannot make that endorsement. When signing the report, the College registrant shall clearly state that they are not the author but endorse the information and recommendations in the record or report. 

4.1.12 College registrants shall record information when the event occurs or as soon as reasonably possible thereafter.

4.1.13 College registrants may use a documentation by exception system but shall only do so where the total record captures the minimum content as set out in Footnote 1.

4.2 Record Maintenance

4.2.1 College registrants shall comply with the requirements regarding record retention, storage, preservation and security set out in any applicable privacy and other legislation. 

4.2.2 College registrants shall ensure that each client record is stored and preserved in a secure location for at least ten years from the date of the last entry or, if the client was less than eighteen years of age at the date of the last entry, at least ten years from the day the client became or would have become eighteen. When considering storing records for a longer period, College registrants shall abide by the following principles: 

i) Where required by law or by an employer’s policy, College registrants shall store and preserve records for a longer period of time. 

ii) College registrants shall store a client record for a longer period only if, based on a reasonable judgment, such longer retention period may be necessary because there is a reasonable possibility that future access to the record may be needed (such as, but not limited to, in cases involving minors, sexual abuse and/or current or future litigation).

4.2.3 College registrants employed by an organization shall acquire and maintain a thorough understanding of the organization’s policies regarding the retention, storage, preservation and security of records, and abide by those policies.

4.2.4 Self-employed College registrants and College registrants who are responsible for records maintenance and retention at their organization (see Principle V: Confidentiality, Interpretation 5.1.8 for more information) shall establish or confirm that there are clear policies related to record retention, storage, preservation and security.

4.2.5 College registrants shall dispose of records only after the time frames described in Interpretation 4.2.2 have elapsed. College registrants shall dispose of the contents of records in a way that ensures that the confidentiality of the information is not compromised.

4.2.6 College registrants shall take necessary steps to protect the confidentiality and security of all communications and hard copy and electronic records. 

All client records shall be stored in an area that is inaccessible to persons who have no legitimate interest in the records. Hard copies shall be secured by lock and key and electronic records shall be password protected. 

4.2.7 An electronic system containing social work and social service work records shall: 

• require a private access code or password; 
• maintain an audit trail that: 

i) records the date and time of each entry of information for each client; 

ii) indicates any changes to the recorded information; and 

iii) preserves the original content of the recorded information when changed or updated; 

• allows for the recovery of files, or otherwise provides reasonable protection against loss of, damage to, and inaccessibility of information; and 
• provides for a paper printout of the record.

4.2.8 Self-employed College registrants and College registrants who are responsible for complying with privacy legislation (see Principle V: Confidentiality, Interpretation 5.1.8 for more information), who cease practice shall either: 

(i) maintain their client records in accordance with Interpretation 4.2.2 ; or 

(ii) make arrangements to transfer the records to another College registrant or other regulated professional.

4.2.9 If a College registrant who ceases practice makes arrangements to transfer their records to another College registrant or other regulated professional, the College registrant shall: 

i) ensure that the other College registrant or regulated professional first agrees in writing to comply with Principle IV and the Interpretations set out in Principle IV; 

ii) make reasonable efforts to give notice to their clients of the future location of their records, unless they are required, under any applicable privacy or other legislation, to obtain their clients’ consent to such transfer, in which case they shall obtain their clients’ consent; and 

iii) ensure that they meet all requirements regarding the transfer of records set out in any applicable privacy and other legislation.

4.2.10 If a College registrant transfers their clients to another College registrant or regulated professional, or if the client requests a transfer to another service provider, the College registrant shall ensure that they meet all requirements regarding the transfer of records set out in any applicable privacy and other legislation.

4.3 Access and Correction of a Record

4.3.1 College registrants shall comply with the requirements regarding access to and correction of client information including personal information in a record as set out in applicable privacy and other legislation. 

4.3.2 College registrants employed by an organization shall acquire, maintain an understanding of, abide by, and inform clients and/or their authorized representative about the organization’s policies regarding access to and correction of information in a record. 

4.3.3 Self-employed College registrants and College registrants who are responsible for complying with privacy legislation (See Principle V: Confidentiality, Interpretation 5.1.8) shall establish and communicate to their clients clear policies regarding access to and correction of information in a record.

4.3.4 College registrants shall provide the client or the client’s authorized representative with access to the client record in accordance with any applicable privacy and other legislation, unless this is prohibited by law or the College registrant is otherwise permitted to refuse access.

4.3.5 College registrants shall refer to and follow relevant legislation when determining whether a person is a client’s authorized representative.

4.3.6 College registrants shall provide clients or their authorized representatives with reasonable access to the client’s record or such part or parts of the record as is reasonable in the circumstances. Clients and/or their representatives have the right to receive an appropriate explanation from the College registrant about the information in the client record, unless otherwise prohibited by law.

4.3.7 Where College registrants are prohibited by law from providing access to information in a record or otherwise permitted to refuse access to information in a record, they shall comply with the requirements regarding a refusal to provide access set out in applicable privacy and other legislation. 

4.3.8 Where College registrants refuse access to the record, they shall inform the client of the reason for refusal and the recourse available to the client if they disagree. 

4.3.9 When the record includes information that pertains to more than one client and providing access to a record could therefore mean disclosing information about another person, College registrants shall provide access to information that pertains only to the individual who has requested access unless the other person(s) has consented to the disclosure of information about themselves.

4.3.10 College registrants shall preserve the integrity of client records. If a client disagrees with the accuracy or completeness of information in a record and wishes the record amended, College registrants shall comply with the requirements of any applicable privacy and other legislation with respect to the correction of the record. 

4.3.11 If a client disagrees with the accuracy or completeness of a record and wishes the record amended, College registrants may incorporate into the record a signed statement or an electronic entry authorized by the client specifying the disagreement and the client’s correction. College registrants shall not obliterate any incorrect information in the record.

4.4 Disclosure of Information from a Record

4.4.1 College registrants shall inform clients early in their relationship of any limits of client confidentiality, including with respect to the client record. When clients or their authorized representatives provide consent to disclose their information to third parties, College registrants shall document this and disclose information from the record within a reasonable time. Consent shall be documented and must identify: 

(i) the information that is to be disclosed, for example a partial record, the entire record, or a summary of the registrant’s contact with the client; 

(ii) the party or parties to whom the information is to be disclosed; and 

(iii) any limits to the consent. 

4.4.2 If, in the registrant’s professional judgment, disclosure of information from the record to a third party could result in harm to the client, College registrants shall make a reasonable effort to inform the client of the possible consequences and seek to clarify the client’s consent to such disclosure. Registrants may disclose information from the record to third parties without the client’s consent only if disclosure is required or allowed by law. (See also Principle V: Confidentiality, Interpretation 5.2.4) 

4.4.3 When College registrants receive a request from a third party to disclose information from a record that pertains to more than one client (for example a couple, family, group, community agency, government department, or other organization/business) College registrants shall obtain consent to the disclosure of information from all the clients before information from such record is disclosed to the third party. 

4.4.4 When College registrants receive a request from a client to disclose information from a record that pertains to more than one client, College registrants shall provide access to information that pertains only to the client who has requested access (see Interpretation 4.3.9) and, before disclosing information that pertains to any other client, obtain consent to the disclosure from each of them.

4.4.5 College registrants who are served with a formal notice or subpoena to produce client records before a court and who are of the opinion that disclosure would be detrimental to the client, should themselves, or through legal counsel, advocate for non-disclosure to the court. If the College registrant is unsuccessful in their advocacy, the records must be disclosed as requested in the formal notice or subpoena. 

4.4.6 College registrants shall comply with the requirements regarding the use or disclosure of information for research or educational purposes set out in any applicable privacy and other legislation.

4.4.7 College registrants may permit client records to be used for the purpose of research or education, but shall first ensure that any identifying information has been removed and clients’ anonymity is protected. (See also Principle V: Confidentiality, Interpretation 5.1.11)

4.4.8 A College registrant or other regulated professional to whom another College registrant’s client records have been transferred, shall comply with the aforementioned interpretations regarding access and disclosure with respect to the transferred records. 

FOOTNOTES

1. Information in the social work and social service work record with respect to each client includes the following: 

(i) Identifying information regarding the recipient of services (individual, family, couple, group, agency, organization, community);Depending on the nature of the services provided, identifying information may include: 

a) name, address, telephone number of each client(s); 

b) date of birth of each client(s); 

c) where available, name, address, and telephone number of a person(s) to be contacted in case of emergency; 

d) name, address, telephone number(s) of the main contact person or position, if different from; and 

e) sponsors, funders, accountability. 

(ii) The date, initiator, purpose of the social work or social service work referral, where relevant, and, if significant, the setting of the first professional encounter with the client; 

(iii) Where applicable, the key elements of the contract or working agreement, namely: client, contracted services, provider of services, fee, reimbursement schedule, and time period for completion of services; 

(iv) The time period of involvement if not specified in (c); 

(v) The date of completion/termination, where relevant, and if significantly different from (c), an explanation for the difference; 

(vi) Particulars of the social work or social service work process, as applicable: 

a) the history obtained by the registrant; 

b) assessment, diagnosis, formulation and plan; 

c) treatment and other interventions, e.g. facilitation, advocacy, transfer of skills, development of action plans; 

d) outcome or results and evaluation; 

e) referrals made by the registrant; 

f) recommendations; and 

g) other services, e.g. verbal and/or written reports/briefs/analyses, research studies and/or their individual components, presentations/speeches/lectures, management related services, stakeholder consultations and professional opinions 

(vii) Consents, releases or authorizations pertaining to the intervention or the communication of information about the client; 

(viii) Fees and charges administered, if any.