Everything You Need to Know: Documentation in Private Practice

Developing and maintaining quality case records and implementing prudent documentation practices is essential for the social worker in private practice.  The NASW Code of Ethics provides all social workers with a comprehensive set of guidelines outlining professional norms, while the NJ Social Work Statutes and Regulations and Federal HIPAA Laws prescribe legal directives around professional conduct for social workers practicing in New Jersey.  The primary goal of all three documents is to protect the client by establishing the “Standard of Care” for the professional practice of social work, but none specifically address the unique experience of the private practitioner.   In this workshop, the presenter will compare and contrast how these and other relevant documents address the characteristics of a case record that complies with current ethical and legal standards for social workers in private practice. Attendees of this workshop receive an in-depth view of the clinical and financial elements of the case record; progress notes; records retention and destruction; confidentiality and privacy and the release of the case record; and clients and others access to the case record.