Recording considerations
This key information covers a number of areas that need to be considered when recording; including where children and young people's information is recorded, ethnicity information, important components in recording and recording of emails.
What are the three records containing children and young people's information?
Visiting folder
Visiting folders are generally used to record information obtained from telephone calls, visits, meetings or case conferences when this information is not immediately recordable on the computer system. Written notes must be factual, detailed and legible, with numbered, dated and author designated pages. Notes from the visiting book are then recorded in an expanded format on the child or young person's computer record as soon as possible.
Paper-based file
The paper file holds hard copies relating to a child or young person. This includes court documents, correspondence, plans, reports and visiting book notes.
Computer system (CYRAS)
The computer record is the primary record we use to record the child or young person's information. It is important that casenotes on CYRAS are concise, accurate, written in a professional manner and focused on information that adds value to the social work assessment/intervention, or understanding of the family's situation.
All casenotes and information recorded is discoverable under our obligations under the Privacy and Official Information Act.
It is important that when we receive information which may protect the people we are working with from potential harm (e.g. the existence and details of protection orders) this is recorded in the ‘Contact notes’ section on the CYRAS person details screen for each person affected.
What are the important components in recording casenotes?
When recording information relating to children or young people, it should be ensured that all casenotes:
- are timely
- are structured with a clear and logical flow
- contain correct spelling and grammar
- are free of acronyms and jargon
- distinguish between facts, observations and opinions
- are written in a way that would enable them to be shared with whānau or family.
When referring to specific interviews/discussions, it is important that casenotes contain:
- the mode of contact (e.g. in person, telephone call, home visit)
- an indication of who initiated the contact and who was involved
- the full name, job title and agency of all professionals involved.
Casenote headers should clearly identify the content of the casenote so that they can be easily recognised for future reference.
How are e-mails recorded?
E-mails sent from staff are official, documented communications from Oranga Tamariki. When communicating with whānau or family and professionals via e-mail, thought must first be given to whether this is the most appropriate form of communication.
Tone, demeanour and the appropriateness of the content should be analysed before copying and pasting e-mail communications into children and young people's records. E-mail communication is typically more casual than other forms of communication, and may include personal information that is inappropriate as part of a child or young person's record.
How do we collect and record ethnicity information?
- Ethnicity and affiliation questions should be addressed at an early interview when basic data (name, address, telephone number, etc) is collected or verified.
- Children, young people and their whānau or family should be advised that social workers are required to seek and record ethnicity-related data. Provide reasons if requested.
- Māori children and young people and their whānau or family should be asked how they perceive themselves in terms of iwi affiliation. Two affiliations may be recorded; and if unclear about their affiliation, whānau could be asked where they go for tangi as this may identify the marae or area visited, usually suggesting a link to an iwi.
- Children, young people and families from the Pacific Islands should be asked about their island group and/or village, and the appropriate affiliation(s) identified. This should be entered with a supporting casenote explaining how affiliation was confirmed.
- Those children, young people and whānau or family who identify themselves as 'Other' should be asked about their country of origin and this information should be recorded.
- If a child or young person and their whānau or family do not know or refuse to disclose affiliations, this should be recorded as 'Unknown' or 'Refused' with a supporting casenote explaining why ethnicity and iwi affiliation is not recorded.
- Staff members can be a good source of information that have knowledge about significant people within a whānau/hapū/iwi.