Policy
Case recording
Case recording helps us uphold the mana and understand and tell the story of those we work with, including tamariki, rangatahi and their whānau or family. It also helps us understand our engagement with wider networks including hapū and iwi during a case.About case recording
Kaimahi have professional, ethical and legal obligations to maintain full and accurate records. People whose information is recorded in case records have the right to ask for access to information about themselves.
CYRAS and CGIS are the online case recording systems used by Oranga Tamariki.
Social Workers Registration Board
Code of ethics | Aotearoa New Zealand Association of Social Workers (ANZASW)
When this policy applies
This policy applies to:
- case recording for all tamariki and rangatahi we work with, and their family, whānau, hapū and iwi
- case recording across all stages of our work, from intake to case closure
- all kaimahi who record information on CYRAS and CGIS, including:
- administrators
- care and protection, youth justice and adoption social workers
- caregiver social workers
- care and protection and youth justice coordinators
- contact centre staff
- practice leaders
- supervisors
- residence staff
- youth workers
- other specialist staff (for example, psychologists).
The responsibility for recording additional information received for a tamaiti or rangatahi rests with the person who receives the information. If they are not the allocated social worker, they must ensure the additional information is brought to the attention of the allocated social worker or their supervisor.
Purpose of case recording
Case recording is a vital element of social work. It supports good practice, accountability and quality assurance.
We must record information that we receive, gather and share at all stages of our involvement with:
- te tamaiti or rangatahi
- their family, whānau, hapū, iwi and family group
- caregivers
- iwi and other social and community services
- other government agencies
- family group conferences
- courts
- other practitioners
- victims of offending by tamariki and rangatahi.
Recording our casework supports good practice by:
- providing a record of all information received and gathered
- providing a record of our actions
- setting out the rationale and process for decisions
- supporting our understanding and analysis
- supporting our consideration of how practice aligns with the Oranga Tamariki values and desired ways of working
- supporting critical thought and wider reflection
- supporting continuity and coordination of social work services, including across providers and agencies
- supporting professional supervision.
Case recording contributes to accountability and quality assurance by:
- showing whether practice demonstrates integrity
- supporting practice review
- meeting legal and organisational requirements.
Requirements for recording our work
Information we record about casework must always be:
- child-focused in the context of their family, whānau, hapū, iwi and family group
- accurate
- succinct
- relevant
- timely – recorded soon after the event.
It must also:
- use respectful language
- have clear headings
- be free of jargon
- avoid use of abbreviations.
Opinion and fact must be clearly differentiated in case recording.
Analysis and decision-making need to be supported by clear reasoning.
Information we record must be verified or confirmed. We must clearly state if any recorded information is awaiting verification and what we are doing to verify it. We must update information when verification is completed.
We record information regarding a case including email, the All About Me plan and genograms.
When attaching documents, including visual media such as photos, use clear titles. If information in an attachment is particularly sensitive, make this clear in the title – for example, include the words 'sensitive content'.
What we record about cases
Our casenotes must be a complete and timely record of our work – all client-level information must be recorded in CYRAS and all caregiver information recorded in CGIS to ensure there is a centralised place of information that is readily accessible.
We record all forms of information relating to our case work, including emails, text messages, phone calls, and visual media such as photos.
What casenotes must cover
Casenotes must cover:
- information that informs our understanding of the safety, care and oranga of te tamaiti or rangatahi and their whānau or family
- the views of those we work with and how we have taken these into account
- social work analysis, decision-making and the rationale behind decisions
- case progress, plans and changes
- other.
Information that informs our understanding of the safety, care and oranga of te tamaiti or rangatahi and their whānau or family
This includes:
- initial information that informs our understanding of the current circumstances of te tamaiti or rangatahi and their whānau and family
- additional information received after an initial report of concern, including information received after a case has recently been closed
- all forms of information, including visual media such as photos and records created on mobile devices such as texts.
Visual information must be attached to the file along with a casenote that states:
- who supplied the item and, if it's a photo, who took it
- details of what the item shows or is intended to show
- what action has been taken in response to the item.
The views of those we work with and how we have taken these into account
This includes the views of:
- te tamaiti or rangatahi
- whānau, hapū, iwi, family group and other people important to te tamaiti or rangatahi
- caregivers
- victims of offending by tamariki and rangatahi.
It also includes:
- how, and from whom, information was gathered
- details of any support provided to enable te tamaiti or rangatahi, or their whānau or family to express their views when they have difficulties doing so because of their age, language, a disability, or other reason.
Building understanding and decision-making
This includes detail about:
- how we have supported te tamaiti or rangatahi and their whānau or family to participate in decisions that affect them
- how we've built understanding about oranga, safety and needs
- use of practice tools
- actions, outcomes and use of practice tools
- key decisions made and the rationale for these decisions
- discussions and decisions made during supervision
- how we have engaged and supported tamariki and rangatahi when there are allegations of harm – including detail about how the steps required in the allegations of harm policy have been undertaken.
Case progress, plans and changes
This includes information about:
- how we have supported te tamaiti or rangatahi and their whānau or family to participate in plans that affect them
- any changes to plans and the rationale for them
- actions taken
- any significant circumstances relating to those actions – for example, the circumstances surrounding the removal of a pēpi
- milestones relating to progress on plans.
Other
This includes:
- personal and demographic details of te tamaiti or rangatahi and their whānau or family
- how we are supporting the health of te tamaiti or rangatahi as set out in the National Care Standards
- how we are supporting a record of important life events for te tamaiti or rangatahi.
Support to maintain and improve health – section 35 of the National Care Standards Regulations 2018
Personal and demographic details
We must accurately record personal and demographic details of te tamaiti or rangatahi and their whānau or family. We must explain why we need this information – for example:
- information about ethnicity to support culturally appropriate responses
- names and relationships to explore support networks
- accurate addresses to provide services
- information about gender so we can respect gender needs.
We need to be sensitive to those wanting to withhold this information by seeking to understand and work through underlying barriers to this information being shared.
For each tamaiti or rangatahi and key whānau or family member, we must record (or note when information has been withheld):
- names and relationships accurately
- information about:
- ethnicity
- cultural identity
- gender
- up-to-date information, especially:
- addresses
- placement records
- legal status.
Recording ethnicity and cultural identity
We must record the ethnic identity of all tamariki, rangatahi and whānau or family we work with when we create their person record. Knowing and confirming the full ethnic identity of tamariki and rangatahi is pivotal to guiding any interventions. Include all ethnicities identified in the person record.
If a person wishes to withhold information about their cultural identity, we must seek to understand why and then try to address their concerns.
If we haven't been able to ascertain and confirm ethnicity and other cultural connections, engage with kairaranga ā-whānau and/or others, as appropriate, to assist with understanding a person's cultural identity.
It is important that Oranga Tamariki has comprehensive ethnicity data to help us:
- understand and respond to needs more effectively
- support whakapapa, whanaungatanga and Pacific identity
- provide more effective services and resources.
We can understand and respond to needs more effectively by:
- knowing the cultural connections of tamariki, rangatahi and their whānau or family
- establishing, maintaining or strengthening tamariki, rangatahi and whānau or family sense of belonging and cultural identity
- ensuring tamariki and rangatahi Māori and Pacific children and young people receive specific entitlements – for example, some iwi have financial grants available for tamariki and rangatahi affiliated with them.
We can support whakapapa, whanaungatanga and Pacific identity by:
- supporting tamariki, rangatahi and whānau Māori and Pacific children, young people and families to:
- know their whakapapa – connections to people, place and knowledge
- achieve mana tamaiti, their deep intrinsic worth and potential
- be connected to, supported by and/or cared for by members of their whānau, hapū, iwi, marae or who can support Pacific cultural identity
- helping social workers and coordinators identify and engage in whanaungatanga (purposeful relationships)
- supporting placing tamariki and rangatahi Māori to live with members of their whānau, hapū or iwi and Pacific children and young people with those who can support their cultural identity
- fulfilling our obligations under the Treaty of Waitangi.
We can provide more effective services and resources by:
- delivering services in a culturally appropriate manner
- identifying significant communities of interest
- identifying when specific cultural and language skills and resources may be required – CYRAS has a field for recording languages spoken
- evaluating the effectiveness of targeted programmes.
Staff resource: CYRAS Handbook – Entering information into the demographics tab
There are dropdown menus in the demographics section of the 'Person details' section in CYRAS to assist with recording detail of Māori and Pacific identity.
Recording Māori identity
We have obligations to record iwi affiliation and information about whānau, hapū and marae. Kairaranga ā-whānau can help identify connections to iwi, hapū and marae for tamariki and rangatahi Māori.
Practice for working effectively with Māori
Recording Pacific identity
For children, young people and others with Pacific identity, record which ethnic groups they identify with. Include information about the specific island, village and/or area they are from or have family connections to.
Recording gender
We must be respectful when we record gender identity for tamariki, rangatahi and others. Gender identity is self-defined. It is a person's internal, deeply felt sense of being male, female, gender queer, trans, non-binary, gender fluid or other.
We must record the gender someone identifies with in the person record. CYRAS and CGIS fields allow male, female, or gender diverse to be recorded. If appropriate, other notes about gender can be added to CYRAS and CGIS.
We must be open to change the gender recording if participants express a wish to be known differently.
Genograms
A genogram must be created for each tamaiti or rangatahi when a family group conference is required. It describes the composition of the whānau or family of all parents, and key relationships for up to 3 generations. The genogram must be recorded in CYRAS.
Other more detailed whakapapa information for tamariki and rangatahi Māori must not be recorded in CYRAS. It is sensitive information that belongs to whānau.
In CGIS, relationship maps are created automatically when relationships and roles are added to the caregiver and their household.
Information sharing and the principles of mana tamaiti, whakapapa and whanaungatanga
Recording information about disability
Disability and impairment must be assessed, recorded and reviewed regularly. If there is new information, records must be updated. This helps us provide the right support to tamariki, rangatahi and whānau or family with disabilities and impairments.
Assessing disabilities
Oranga Tamariki has the following key tools for identifying disabilities and impairments:
Youth justice health and education assessment programme (DOC 114 KB)
We must verify disability information before adding it to CYRAS. It is important that disability information is accurate. If we are waiting for information about possible disabilities, we must add this detail and update it if a disability is identified. We need to check that any existing information about disability is still up to date.
Kaimahi should contact their Regional Disability Advisor or other relevant professionals if a more detailed assessment relating to the disability is needed to help build understanding – for example, for suspected neuro disabilities or mental health needs.
Guidance: Practice when working with disabled people
Recording disability
Information about disability or impairment is recorded in the person characteristics box in the Person Details section on CYRAS. Multiple characteristics can be entered, including about health (such as mental health) and behavioural disorders.
Disability information we record must reflect the gateway assessment (if this has been completed), the assessment report and the All about Me plan.
Guidance: Practice when working with disabled people
Staff resource: Adding information to the person record in CYRAS | CYRAS handbook
Tamariki and rangatahi in care or custody
There are specific recording requirements for tamariki and rangatahi:
- in the care or custody of the chief executive
- when the chief executive continues to provide support after permanent care is established
- when responding to allegations of harm.
For these tamariki and rangatahi, we must record in CYRAS:
- demographic details
Personal and demographic details - current legal status
Legal statuses for custody, guardianship or placement - the care arrangement, including caregiver details and their relationship to te tamaiti or rangatahi.
This information must also be recorded for tamariki and rangatahi in the care or custody of a care or youth justice partner.
For those in our care or custody, we must also record:
- planning for safe, stable and loving permanent care
- details of any permanent care arrangements
- a financial plan that reflects their care situation.
When te tamaiti or rangatahi is living in the care of a care partner (section 396 provider) caregiver, the name of the caregiver must be recorded. This includes respite caregivers.
Details of these caregivers are recorded in the Participant tab in CYRAS. This may require establishing Person Details.
Policy: Ensuring a safe, stable and loving home for tamariki in care
Recording information sharing
We must record in CYRAS and CGIS all information sharing activities relating to te tamaiti or rangatahi and their whānau or family.
Correction of information
Information stored by Oranga Tamariki must be accurate. When it comes to our attention that information stored is inaccurate, we must verify it and then correct it. Using unverified information, or not correcting incorrect information, breaches the privacy of the person it is about.
Staff resource: CYRAS correction requests – template
People can request that information about them in CYRAS and CGIS be corrected. If we decline or are unable to make a correction, we have an obligation under the Privacy Act 2020 to offer to attach a Statement of Correction to the record. This allows the complainant to present their view alongside our records.
Practice framework prompts for this policy
Our practice is framed in te Tiriti o Waitangi (the Treaty of Waitangi), based on a mana-enhancing paradigm for practice and draws from te ao Māori principles of oranga within the context of our role in statutory child protection and youth justice in Aotearoa New Zealand. Our practice framework helps us make sense of and organise our practice.
Ngākau whakairo
How will I make sure that I uphold the rights and mana of the people I am writing about in my case recording? What do I need to be aware of to ensure that the narratives, lived experiences and views of tamariki, rangatahi, whānau or family are recorded fairly, accurately and in a way that they understand?
Ngākau whakairo practice framework domain
Whai mātauranga
What sort of knowledge do I preference in my recording practice? What steps am I taking to ensure I reference a wide range of knowledge sources in my recorded work?
Whai mātauranga practice framework domain
Whai oranga
Why is it important for me to understand and accurately record the ethnicity of tamariki, rangatahi and their family, whānau, hapū, iwi or family group? How will Te Toka Tūmoana or Va'aifetū help me understand the sensitivities or cultural practices that I need to consider when recording information about this whānau or family?
Whai oranga practice framework domain
Whai pūkenga
How will I differentiate opinion from fact in my case recording? Why is this important? What skills and behaviours will help me do this?
Whai pūkenga practice framework domain
Whai ākona
How do I feel about personal information that is recorded about me or my whānau or family? How would I like information about myself and my own whānau or family to be treated? Am I comfortable with the way I'm sharing the information I have recorded?