Describe the three main reasons why documentation and record keeping are important to human services organizations

Documentation and record keeping are important to ensure accountability, facilitate coordination of care between providers and for service improvement. However, the importance of documentation and record keeping may be overlooked/overshadowed by the focus on direct services to clients.

1. Continuity of care. Records provide a case history and a more holistic picture in order to follow-up on services or try different approaches to assist the client. This is especially for clients with long-term or complex needs, or who require multiple services. Accurate and up-to-date recording is important especially when there is an emergency and the staff-in-charge is not available (due to illness, vacation, resignation, etc.). Good records and documentation will facilitate communicationbetween service providers to ensure coordinated, rather than fragmented, service.

2. Accountability. It is important to be able to provide relevant client information at any given time and the organisation’s response to their needs. The information may be needed to respond to queries from stakeholders, who may include the client’s family, funders, donors or the courts. One important source of information is the client records. Documentation forms the nature of the professional relationship with the client. Information on problems encountered and the agency’s response would assist in the event of a crisis or investigations.

3. Service improvement. Well-documented records can also lead to improved services to the clients by helping the staff organise his/her thoughts. Aggregated client information can also facilitate serviceplanning, service development and service reviews. The information can also form primary data to conduct evidence-based research.

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