The purpose of this qualitative grounded theory study was to explore and examine the factors that led to the creation of multiple record entries, and present a theory on the impact the problem has on the business performance of health care organizations. A sample of 59 health care professionals across the United States participated in an online…

The widespread adoption of research-supported treatments by mental health providers has facilitated empirical development of quality assurance (QA) methods. Research in this area has focused on QA systems aimed at assuring the integrity of research-supported treatment implementation, while examination of QA systems to assure appropriate…

Rich with the histories of families and steeped in traditions, schools often embrace all that is good within a community. In fact, the school is often where families, students, and staff choose to memorialize the achievements, contributions, and sacrifices of those who learned or worked within the school's classrooms and corridors. A school's…

The Problem-Oriented Record can be used as a tool to facilitate accountability by explaining what actions have been taken and why. It allows the social worker to plan and assess interventions in terms of his predefined goals. (Author)

Asserts that, although the need to keep client records is clear, there is little information available as to how to construct client record. Presents guidelines for what data should be contained in intake summaries, along with assessments, treatment plans, case notes, and other supplemental materials. (Author/NB)

Reviews trends in and current uses of child welfare case recordkeeping, and proposes a flexible format for organizing public child welfare case records. In the design of recordkeeping systems, recognition must be given to the multiple purposes case records are put to and the needs and demands of casework staff. (MDM)

Case records and recording practices are an important but ignored part of social casework. Social work recordkeeping methods have coincided with machine technology. At the Benjamin Rose Institute, recording in social work has gone through four clearly differentiated phases: (1) registered-typed records; (2) abbreviated diary; (3) process…

Describes record linkage as a data-generating technique, and presents a method for linking client records to live and stillbirth records, using 32,974 births in the Cleveland (Ohio) area. Biases that can enter the linkage process and general research issues related to record linkage are discussed. (SLD)

Addresses legal and professional responsibilities of mental health counselors to maintain adequate and timely client records. Discusses importance of documentation and recordkeeping, use of client records in court, characteristics of adequate records, recording content of sessions, potentially damaging records, and correcting and storing records.…

Provides guidelines for the effective writing of psychoeducational reports based on a literature review and logical analysis. Presents a relatively standard report outline with specific recommendations for each section. The literature reviewed consists of surveys of consumers' opinions, research studies, and books and articles describing the…

Contends that recording has become an administrative rather than a clinical activity, retroactive rather than proactive, bringing its usefulness to clinical practice in question. Presents suggestions for improving the clinical record and for returning it to its proper place as a vital component of clinical practice. (LLL)

Provides school counselors with a procedure to record data, organize information according to published professional standards, and provide accountability for school counseling. (Contains 19 references.) (GCP)

Supervisors have legal liability for the therapists' handling of cases under their supervision, and documentation is the only way to demonstrate appropriate supervisory behavior. Presents the Case Review Form, a standardized review form, along with examples of its usage. (JPS)

Discusses a record-keeping system for school counselors. Examines objectives in maintaining such a system, such as documenting various counseling contacts, the content of one such system, and the evolution of forms used for gathering information. Provides an evaluation and includes the benefits derived from such a system. (RJM)