DFCS Online Policies & Procedures

  DFCS Online Policies & Procedures

   <<< Return to OPP Table of Contents
Handbook 10: Contacts and Visitation
10-3  Contact Documentation Standards
Contacts and Visitation
10-3  Contact Documentation Standards
Reference Points
Overview
DFCS Policy
What To Include in the Documentation
What to Omit in the Documentation
Documenting Contacts in Referrals
Documenting Contacts in Cases
Documentation Quality Standards
Printing and Maintaining Contacts
Corrections to Documentation
Updating Case Plans
Other References


Reference Points
Effective Date: 5/1/06
Last Updated: 11/3/09
 Legal Basis:
Popup Window Evidence Code 1271
PDF All County Letter (ACL) 08-65: Documentation of Interpretive Services
PDF California Department of Social Services (CDSS) Manual of Policies and Procedures (MPP) Division 31 Sections 31-320 through 31-335
 Non CWS/CMS Forms:
bullet SC 909 - not online
 CWS/CMS Forms:
bullet Services Management Section: Contact Notebook
bullet Case Plan Management Section: Case Plan


Overview  

The standards outlined in this chapter will provide social workers with the framework to document their observations, activities, actions taken, etc. in a consistent manner which will support:

  • Child safety
  • Reasonable efforts
  • Timely permanency
  • Compliance with contact requirements set forth in California Department of Social Services (CDSS) Manual of Policies and Procedures (MPP) Division 31 Sections 31-320 through 31-335
  • Writing more thorough court reports
  • Providing other DFCS staff with a clear and accurate picture of the case so that they can provide needed services (e.g., Officer-of-the-day, SW I's)
  • Assisting both managers and social work supervisors to make sure that social workers have:
    • Taken all the necessary steps to gather all the relevant information necessary during his or her assessment to ensure the safety of the child.
    • Recorded the findings of their assessments, which supports the outcome of increased safety to the child and/or that the family was provided the necessary services to support the child remaining in the home.
    • Evaluated and assessed the safety of the child and his or her environmental, physical, emotional, medical and educational well-being on an ongoing basis.
  • Providing evidence in court.
    • Contact notes are subject to discovery.
    < Return to OPP Table of Contents | ^ Back to Top of Page
   
DFCS Policy  
  • Other contacts, which do not constitute mandatory contacts, may be documented:
    • In the CWS/CMS Contact Notebook, Contact Page (preferable location) or
    • On form SC 909 in handwritten form.

  • All mandatory contacts made during a month must be entered into the CWS/CMS Contact Notebook as soon as possible following the contact but no later than by the last day of the month in which the contact occurred. 
    • For example, all mandatory contacts made in March must be entered into CWS/CMS by March 31.
  • At the end of each entry in CWS/CMS, the social worker types his/her name and worker number. 
    • If documenting on an SC909, the social worker signs his/her name and prints the name if the written signature is not legible.
    < Return to OPP Table of Contents | ^ Back to Top of Page
   
What To Include in the Documentation  

The types of events that social workers should document include:

  • Home visits, placement visits, school visits, and office interviews.
  • Telephone calls, both sent and received, from clients, service providers and collaterals.
  • Mail, both sent and received, from clients, service providers and collaterals.
  • Meetings with representative of other agencies, including the purpose and outcome of the meeting.
  • Referrals for services.
  • Tasks related to placement transitions, ILP and emancipation.



When documenting an in-person contact with the client, the social worker includes information on:

  • Where the visit took place.
  • Who was present at during the visit.
  • If the visit was scheduled or unscheduled.
  • How the social worker communicated with the client, if the client's primary language is one other than English.
  • What services the social worker offered the client, if any were offered during the visit.
  • Observations made during the visit.

 

When documenting telephone calls, the social worker includes information on:

  • To whom the call was made.
  • Who made the call.
  • The date and time of the call.
  • The conversation that took place or the message left on voice mail.
    < Return to OPP Table of Contents | ^ Back to Top of Page
   
What To Omit in the Documentation  

Items that social workers should omit from contacts include:

  • Personal reminders for the social worker.
  • The content of discussion or written communication with County Counsel or a Court Assistant.
    • To record communication with County Counsel, a "Privileged for Counsel" form is available.
     
  • Names, addresses and telephone numbers associated with confidential placements.
    • Upon completing the Placement/Address Change Form (SCZ17) and submitting it to the Placement Tracking Team (PTT), the information from the SCZ 17 will be recorded in CWS/CMS.  Workers can then view the child's location on the Address Page for the child.
     
  • "Editorial" opinions, comments and conclusions regarding clients, co-workers, therapists, and supervisors.
  • Disagreements among/with co-workers, supervisors, managers and administrators.
  • Disagreements with Department policy.
  • HIV testing.
    < Return to OPP Table of Contents | ^ Back to Top of Page
   
Documenting Contacts in Referrals  

When entering contacts in CWS/CMS, complete all mandatory fields on the Contact Page.

  • List in the "participants" field only those individuals seen or spoken to during the contact.

When documenting contacts with the child(ren), parents and others involved in a child abuse/neglect referral, some of the major items that the narrative content of each contact should include are:

  • For all in-person contacts:
    • The language in which the contact was conducted, if other than English.
    • Other documentation requirements when interpreter assistance is needed.
    • The purpose of the contact
    • Who was present
      • Include each person's name, age and relationship to the child
      • If child is residing in the family home, account for the whereabouts of all the children in the home, and, if they are not seen, the plan to see them.
      • Where it took place
        • If in the family home, describe the appearance of the home inside and outside.
      • The outcome
      • What time it began
      • If the visit was scheduled or unscheduled

  • A precise, objective summary of the discussion with factual observations.
    • Describe the appearance of each individual seen, such as each person's affect, tone of voice, behavior, attire, cleanliness, interaction with each other, marks, bruises, etc.

  • Each allegation listed on the referral and documentation of any observations of any new allegations discovered during the course of the investigation.
    • Describe the circumstances of each allegation.
    • When documenting an individual's statement, document the statement as follows: "Mary stated that..."
    • Document statements verbatim, whenever possible.
    • If the child is non-verbal and/or too young to make a statement, enter the child's name followed by, "The child is non-verbal." or "The child is too young to make a statement."

  • As much family history as can be gathered from family members, In the event it appears that the family will be in need of ongoing child welfare services, 
     
  • Any supporting documentation providing by the parents to address the allegations.  For example: Immunization Records, school reports, etc.  
  • Reported health, mental health or substance abuse issues regarding all family members.  
     
  • Services offered or provided.  
     
  • The language in which the interview was conducted, if the client's primary language is other than English.  
     
  • When appropriate, Calabretta language documenting consent to enter.  
     
  • All attempted contacts with family members.




When documenting contacts with a reporting party or collateral, the following standards are to be use in the contact note narrative.

  • When referring to an individual, use that person's name and relationship to the family.
    • If the contact is with a friend, neighbor, professional or other agency, etc., record the person's/agency's name, relationship to the family (e.g., neighbor, therapist, etc.) the person's address and direct telephone number.
     
  • When entering an individual's statement, document the statement as follows:  "David Jones, the family therapist stated that..."
    • Document statements verbatim, whenever possible.
  • Document the purpose of the contact and a description of the contact.
    • For example: "Contacted by Dr. David Jones by telephone where he reported that..."
     
  • Document all attempted contacts with the reporting party and/or collateral contacts.

NOTE: To facilitate the entry of contacts with a collateral, utilize the Collateral Notebook to enter the name, telephone number and address of collateral contacts.


When using CWS/CMS, spell check should be used before saving the information to the database.

    < Return to OPP Table of Contents | ^ Back to Top of Page
   
Documenting Contacts in Cases  

When entering contacts in CWS/CMS, complete all mandatory fields on the Contact Page.

  • List in the "participants" field only those individuals seen or spoken to during the contact.

Some of the major items that the narrative content of each contact should include are:

  • For all in-person contacts:
    • The purpose of the contact
    • Who was present
      • Include each person's name, age and relationship to the child
      • If child is residing in the family home, account for the whereabouts of all the children in the home, and, if they are not seen, the plan to see them.
    • Where it took place
      • If in the family home, describe the appearance of the home inside and outside.
    • The outcome

  • A precise, objective summary of the discussion with factual observations.
    • Describe the appearance of each individual seen, such as each person's affect, tone of voice, behavior, attire, cleanliness, interaction with each other, marks, bruises, etc.

  • Statements made by any individual.
    • Document statements verbatim, whenever possible.
    • If the child is non-verbal and/or too young to make a statement, enter the child's name followed by, "The child is non-verbal." or "The child is too young to make a statement."

  • Services or referrals offered or provided.  
     
  • Review of the status of work with the case plan. 
     
  • The language in which the interview was conducted, if it was a language other than English.  
     
  • If there is a contact waiver, the duration/frequency and anticipated time of the next visit.

 

    < Return to OPP Table of Contents | ^ Back to Top of Page
   
Documentation Quality Standards  

When documenting contact information, the social worker shall adhere to quality standards. Contact information must be:

  • Legible
    • If documentation is handwritten and others cannot read the notes, they are little value as evidence in court, as preparation material for County Counsel, as a record for audits or as data source for the Officer-of-the-Day and/or supervisor.

  • Truthful
    • All contact documentation must reflect actual contact or actual attempted contact made with the participant.  Contacts may not be falsified.  Falsification of contacts is subject to immediate disciplinary action and may lead to termination of employment with the Department of Family Children's Services.
  • Concise
    • There is no need to record verbatim the content of interviews. A summary/factual outline style is most helpful.

  • Current
    • Entries must be recorded at or near the time of the event described. Allowing days to elapse between case activity and its recording will not result in the best notes. At a minimum, all mandatory contacts made during a month must be entered into the CWS/CMS Contact Notebook no later than by the last day of the month in which the contact occurred.

  • Dated
    • Show month, day and year for each entry.
    < Return to OPP Table of Contents | ^ Back to Top of Page
   
Printing and Maintaining Contacts  

Department policy is that social workers are not required to print contacts from CWS/CMS for filing in the case file.  Handwritten hard copies of SC 909's should be filed in the case file.

    < Return to OPP Table of Contents | ^ Back to Top of Page
   
Corrections to Documentation  

The content of the contacts should not be changed once it has been written (although spelling corrections may be made). This is a primary rule for all DFCS staff.  Erroneous information may not be whited-out or blacked-out.

In the event an error is found and/or a revision is necessary, the correct information should be recorded as a new entry. 

  • Date the new entry
  • State that the information in an entry on a previous date (identify the date) was incorrect.
  • Enter the corrected information with the source of the corrected information.
  • Make a notation by the date of the original contact that the information in the entry is incorrect and that the corrected information appears in the contact dated (identify the date).
    • For handwritten contacts, a single line also may be drawn through the incorrect information.

If there is a need to change any other kinds of information in a contact, consult with the supervisor and County Counsel.

    < Return to OPP Table of Contents | ^ Back to Top of Page
   
Updating CWS/CMS Case Plans  

When any change is made to the frequency of contacts, it must be documented in the CWS/CMS Case Plan Notebook by updating the Case Plan.  The effective dates on the hardcopy Contact Waiver must match the dates in the CWS/CMS Case Plan for the Contact Waiver.  The supervisor must also approve the updated Case Plan on-line in CWS/CMS. The approval date of the updated case plan must match the date that the supervisor signed the hardcopy Contact Waiver.

    < Return to OPP Table of Contents | ^ Back to Top of Page
   
Other References  
PDF CWS/CMS Training Guide - Contact Notebook
    < Return to OPP Table of Contents | ^ Back to Top of Page