Question
Should the client’s assessment be kept in the medical record?
Answer
When assessing a client, regardless of the assessment tool that I use, I keep the actual assessment in the client’s record. I currently use an EHR (electronic health record) system, and that system is designed to keep the assessment tools within the client’s chart/medical records.
Even before I used an EHR, I would just keep the assessment in the client’s chart. It is helpful to refer back to the assessment, especially if we are doing it again in a couple months. It is nice to refer back to the assessment and be like, "Okay, before you said you were having thoughts of hopelessness, like constantly, and now you're not."
That also helps us track the client’s progress, and to show if the modality that we are using is working. It is also helpful to keep the complete assessment in the client’s chart because we can always refer back to it, to those really specific issues and not just the score.
This Ask the Expert is an edited excerpt from the webinar, Documentation in Social Work for Private Practitioners, presented by Gabrielle Juliano-Villani, MSW, LCSW
