Client-centred, Co-constructed Records

Records have long played an important role in human service work.  Traditionally they contain assessments, plans, reports, letters, decisions and summaries, held in files by an organisation, and maintained by a worker about a client. Most importantly, traditional record keeping tends to focus on ‘the problem’ that needs ‘solving’. Increasingly, workers and organisations are challenging this view.

What if workers and clients co-create the record?

The practice of maximising the client’s input in the act of recording the support an organisation provides is underpinned by the principles and beliefs of strengths-based practice.

A strengths-based approach is a best-practice framework that serves to foster the conditions in which empowerment and change can occur meaningfully and sustainably in the lives of those who access human services.

Strengths-based principles are as follows:

• All people have strengths and capacities.
• People can change. Given the right conditions and resources people’s capacity to learn and grow can be harnessed and mobilised.
• People change and grow through their strengths and capacities.
• People are the experts on their own situation.
• The problem is the problem; the person is not the problem.
• Problems can blind people from noticing and appreciating their strengths and capacity to find their own solutions.
• People have good intentions.
• People are doing the best they can.
• The power for change is within us.

(McCashen W 2005, The Strengths Approach, p.9, St Luke’s Innovative Resources, Bendigo,  2005)

Client-centred, collaborative practice sees clients as the primary stakeholders. Accordingly, for a service to be effective, stakeholder involvement in the direction and recording of the services provided is critical.

Client-centred, co-constructed recording is firmly aligned with key social work principles that place importance on the values of respect, human rights, autonomy, self-determination and transparency.

Strengths-based recording facilitates genuine empowerment. Co-construction of service folders, collaboratively with clients and workers, can be a therapeutic activity, unlike a worker writing up ‘case notes’ in the seclusion of an office space.

St Luke’s, now part of Anglicare Victoria, decided in 2013 to strengthen its position on the practice of client-centred, co-constructed, collaborative recording. In short, following extensive consultation with agency practice leaders, a set of recording principles and standards were developed aimed at benefiting clients and workers alike. The principles and standards landed on are:.

 PRINCIPLES OF STRENGTHS-BASED, CLIENT-CENTERED RECORDING

Client records are:

• co-constructed by clients and workers
• key tools for promoting safety, healing, growth and change
• clear, relevant and understandable
• focused on strengths, skills, hopes, values, resources, goals and agreed actions
• able to be accessed at a convenient time and in an agreed format
• regularly reviewed to ensure accuracy and relevance.

STANDARDS FOR STRENGTHS-BASED, CLIENT-CENTRED RECORDING

Accountability

• All content of a record is to be regularly scrutinised for accuracy.
• Notes and letters are to be written in the first person (ie ‘I’) and to a named client.
• Each record must contain evidence that the client has been informed of the complaints and appeals processes.

Language appropriate

• The record will use plain English.
• Jargon, acronyms and technical language will be avoided.

Therapeutic

• The people we work with are encouraged to co-construct the record. Workers are expected to maximise client input in designing and contributing to the record.
• The record will reflect the client’s plan and the work towards achieving their goals.
• Letter writing is an essential component of recording.

Socially inclusive

• Clients will have their plans towards health, employment, educational and community connectedness outcomes identified.

Privacy and confidentiality

• Each record must contain evidence that the client understands the legal, ethical and process standards that St Luke’s adheres to in its recording.

Accessible

• Current clients can access their record on any work day providing the worker or a supervisor is present.
• Recorded contacts will be up-to-date and able to be printed within a reasonable time frame upon request.

Client-centred, co-constructed records are in the best interests of the people we work with. Regular review by both client and worker ensures accuracy and clarity, maintaining a level of transparency that ensures all records withstand a high level of scrutiny. A person’s record will be a collaborative effort, constructed ‘with’, and not merely ‘about’, the most important stakeholder. It will contain information that is considered the property of the client, fostering a sense of care and responsibility, held by an organisation, for the keeping of information.

Co-constructed records are immediate and timely in that they can take place during a contact visit, removing the risk of inaccuracy that can occur when completed after the contact occurs.

Records that use both worker and client’s names, are language appropriate, avoid jargon, focus on what is working—as well as what is not—and  that clearly represent the client’s perspective of the service they receive, will be records that promote not only safety, accuracy and accountability, but uphold the dignity and rights of the people, not ‘cases’, they work with.

Andrew Shirres

Practice Development Coach

(We are available to run workshops for organisations on the subject of client recording. You can email us here.)