CWTI Trainings

documentation graphic: woman on computer, man writing

Documentation



Conveying Professionalism

 

Separating fact from opinion

Writing an opinion without specific facts could put you in a position to defend those opinions in Court without the ability to remember why you formed them in the first place.*

Larry's suggestion: Mouse-over definitions of “fact” and “opinion.” Expand on the difference, maybe from literature & training on evidence & the importance of observable, concrete facts as an essential component of professional behavior, much less documentation.


“Mr. Smith showed up for his visit drunk.” *


In this narrative, there are no supporting facts for the caseworker's assertion that Mr. Smith was drunk.




“Mr. Smith showed up for his visit smelling of alcohol. He was unable to stand up on his own, leaning against the wall, and he fell as he walked away from the visiting room. Mr. Smith admitted he had been at the bar earlier today but denied being drunk.” *


In other words, it answers the question, “What evidence do you have to assert that Mr Smith had had too much to drink?” The answer to that question is what you write.

Keep in mind that others may review your documentation, so each narrative must give a clear and unbiased reporting of what happened during each contact.


* Rubin (2000)



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