6600. Documentation

Original Date:  October 17, 2017

Revised Date:  September 1, 2021

Sunset Review Date:  September 30, 2025

Approved by:  Jody Becker, Deputy Secretary


Purpose

This policy provides direction for documenting case and provider-related:

  • Communications
  • Events
  • Activities

Scope

This policy applies to:

  • Child welfare (CW) employees
  • Licensing Division (LD) workers
  • Information Technology Division (ITD) service desk employees

Laws

RCW 74.14A.020  Services for emotionally disturbed and mentally ill children, potentially  dependent children, and families-in-conflict

RCW 74.14A.025  Services for emotionally disturbed and mentally ill children, potentially dependent children, and families-in-conflict-Policy updated

RCW 74.15.020  Definitions

Policy

CW employees and LD workers must document communication, events, and activities related to cases and providers in FamLink.

Procedures

  1. Documenting and Notification of Critical and Administrative Incidents
    1. Caseworkers must immediately notify their supervisor when notified of a:
      1. Critical incident
      2. Administrative incident
    2. Caseworker supervisors must:
      1. Immediately notify the area administrator (AA) and regional administrator (RA) or designee of a critical incident.
      2. Document administrative incidents in the Administrative Incident Response System (AIRS), within 24 hours of being notified.
    3. LD workers must immediately notify their:
      1. LD AA or designee and their supervisor, when notified of a critical incident.
      2. Supervisor, when notified of an administrative incident.
    4. LD supervisors must document administrative incidents in AIRS, within 24 hours of being notified.
    5. RAs, LD AAs or designees must verify critical incidents have been documented in the AIRS, within one hour of being notified.
  2. General Documentation Timeframes
    1. Caseworkers must:
      1. Within three calendar days of completion, document in FamLink:
        1. Initial face-to-face (IFF) contact.
        2. Child victim or identified child abuse interview.
        3. Placements of children or youth in out-of-home care.
        4. Monthly health and safety visits with children and youth, parents, and caregivers.
        5. Safety Assessment/Safety Plan DCYF 15-258.
        6. Public Notice of Nondiscrimination DCYF HR_0012 publication was provided to parents and caregivers at initial contact in CPS investigations.
        7. When qualified interpreters were used at initial contact with individuals, per DCYF Administrative policies:
          1. 6.02 Access to Services for Clients and Caregivers who are Limited English Proficient (LEP).
          2. 6.03 Access to Services for Individuals with Disabilities.
        8. Termination of payment authorization when services are completed, per the Child Care policy.
      2. Within seven calendar days of:
        1. Completion, document in FamLink:
          1. Shared planning meetings (SPM)
          2. Case transfer summaries
        2. Children or youth entering out-of-home care, collect photos of them and document their height and weight, per the Emergency Planning for Children in Out-of-Home Care policy. 
    2. LD CPS workers, within three calendar days of completion must document the following:
      1. IFF contact.
      2. Child victim or identified child abuse interview.
      3. Public Notice of Nondiscrimination DCYF HR_0012 publication was provided to parents and caregivers at initial contact in the investigations.
      4. When qualified interpreters were used at initial contact with individuals, per the following DCYF Administrative policies:
        1. 6.02 Access to Services for Clients and Caregivers who are Limited English Proficient (LEP).
        2. 6.03 Access to Services for Individuals with Disabilities.
    3. Caseworkers and LD workers, within 10 calendar days must complete the following as they occur, unless their supervisor has approved an exception or extension:
      1. Document case or provider-related communication by selecting the appropriate activity type in FamLink, i.e., in-person or phone contact, subject interviews, activities, collateral contacts, other child or youth interviews, and meetings, excluding SPM. Documentation must:
        1. Be complete and accurate.
        2. Include the following in case or provider notes if applicable:
          1. Who was present, with full names and roles.
          2. When qualified interpreters or translations were used.
          3. What occurred.
          4. When the communication occurred, including date and time.
          5. Where the communication occurred.
          6. Reason or purpose of the communication.
          7. Description of the worker’s assessment of the contact including supporting facts or evidence.
      2. Document any communication with the Assistant Attorney General (AAG) in FamLink as “AAG activity” type.
      3. Store hard copies of AAG information in the “Privileged Communication with AAG” or confidential section of the hard case or provider file, if applicable.
    4. Caseworkers and LD CPS investigators, within 15 calendar days of completing children's physical or sexual abuse near verbatim interviews must document near-verbatim interviews that were not audio recorded.
    5. Caseworkers must complete within 30 calendar days from the date of intake, the Safety Assessment/Safety Plan DCYF 15-258 form per the Safety Assessment policy.
    6. LD CPS investigators, within 30 calendar days from the date of intake must complete the Safety Assessment/Safety Plan DCYF 15-258 form in FamLink in licensed foster homes for:
      1. Biological children or youth
      2. Adopted children or youth
      3. Children or youth in a guardianship
    7. Caseworkers, within 45 calendar days of being assigned a Child and Family Welfare Services (CFWS) or Family Voluntary Services (FVS) case must complete the initial Comprehensive Family Evaluation (CFE) DCYF 10-480, per the Family Assessment/Assessment of Progress policy.
    8. Caseworkers, within 45 calendar days from the date of intake for FAR cases must complete the:
      1. Risk assessment using the Structured Decision Making Risk Assessment (SDMRA) DCYF 16-208 form in FamLink, per the SDMRA policy.
      2. Following for families that did not agree to services or consent to keeping the case open for more than 45 calendar days:
        1. FAR Family Assessment (FARFA) DCYF 10-474 form in FamLink per the CPS Family Assessment Response (FAR) policy.
        2. Case closure in FamLink.
    9. LD foster care licensors, within 45 calendar days from the date of intake must complete licensing only investigations, per the Licensing Investigations policy.
    10. LD CPS investigators, within 45 calendar days from the date of intake must complete LD CPS investigations, unless the supervisor approved an extension in FamLink per the Licensing Investigations policy.
    11. Caseworkers, within 60 calendar days from the date of the intake must complete the:
      1. Investigative Assessment (IA) in FamLink.
      2. Risk assessment using the SDMRA DCYF 16-208 form in FamLink, per the SDMRA policy for CPS investigations and Risk Only intakes.
    12. Caseworkers within 120 calendar days from the date of the intake must complete the following for families that participated in FAR services and consented to keeping the case open for more than 45 calendar days:
      1. FARFA DCYF 10-474­ form in FamLink per the CPS FAR policy.
      2. Close the case in FamLink.
    13. CW supervisors must:
      1. Within two business days of receipt from caseworkers, review for approval the Safety Assessment/Safety Plan DCYF 15-258.
      2. Within seven calendar days of receipt from caseworkers, review for approval:
        1. Initial and ongoing CFEs.
        2. Case closure in FamLink.
      3. Every 30 calendar days, document review of safety plans during monthly clinical supervisor case reviews.
    14. LD licensing supervisors within seven calendar days of foster care licensors and relative and adoption home study writers requesting provider closure, they must review and approve the provider for closure in FamLink.
    15. LD CPS investigators’ supervisors must review and approve:
      1. Within two business days of receipt from LD investigators, the Safety Assessment/Safety Plan DCYF 15-258 form.
      2. Within 15 calendar days of receipt from LD CPS investigators, case closure in FamLink.
  3. Documenting Intakes and Use of Photography and Audio Recording
    1. CW CPS and LD CPS investigators must perform their duties consistent with the following the policies:
      1. Intake Process and Response for documentation timeframes.
      2. Photograph Documentation when taking photographs in the course of a CPS investigation.
      3. Audio Recording when either:
        1. Recording children or youth physical or sexual abuse interviews.
        2. Retaining voicemails from parents or caregivers for evidentiary purposes.
    2. Caseworkers and LD workers must follow the Photograph Documentation policy when taking photographs of children or youth in the DCYF placement care and authority or their surroundings.
  4. Documenting Exceptions or Extensions for CW CPS and LD CPS Investigations
    Caseworkers and supervisors must follow the:
    1. CPS IFF Response policy, for exceptions and extensions for IFFs.
    2. CPS Investigation policy, for extensions on CPS and LD CPS investigations.
  5. Documenting and Safeguarding Confidential Information
    Caseworkers and LD workers must perform their duties consistent with the following policies for safeguarding confidential information when working with clients and providers:
    1. Domestic Violence (DV) when documenting safety planning information for:
      1. DV victims using the Specialized DV Assessment.
      2. Witnesses to a crime.
      3. DV victims’ children or youth.
    2. Bloodborne Infections Implementation Practices/Procedures when documenting blood-borne pathogen information about parents, children, or youth.
    3. DCYF Administrative 13.04 Protecting Privacy and Confidential Information to protect client and provider-related information.
    4. Records Management for storage and retention requirements of confidential information and when storing these records temporarily in DCYF share drives, personal folders, desktops, or on handwritten notes.
  6. Documenting Emails and Text Messages
    Caseworkers and LD workers must perform their duties consistent with the following policies:
    1. DCYF Administrative 12.04 Acceptable Use of Information Technology (IT) Resources and the Internet when sending emails containing sensitive or confidential information.
    2. Electronic Communication when creating, receiving, documenting, and storing emails and text messages.
  7. Documenting Corrections to Errors in Case or Provider Notes
    1. Caseworkers or LD workers must complete the following when errors are found in FamLink or additional information needs to be added to a case or providers note:
      1. Correct or add the information to notes that have not been finalized.
      2. Use the “Insert correction note” in FamLink if notes have been finalized.
    2. Caseworkers or LD workers must complete the following when confidential information is put in the wrong case or provider note:
      1. Correct or add information to notes that have not been finalized.
      2. Consult with their supervisor for permission to unlock a finalized case or provider note.
      3. Email the AA, with a cc to the supervisor, to obtain approval to contact the ITD service desk to unlock finalized notes. 
    3. AAs receiving requests to unlock finalized notes must:
      1. Review requests for caseworkers or LD workers to contact the ITD service desk.
      2. Approve or deny requests, and notify the caseworker or LD worker with a cc to the supervisor.  
    4. Caseworkers or LD workers must send approved requests to the ITD service desk.
    5. The ITD service desk must:
      1. Unlock case or provider notes to allow for corrections.
      2. Notify caseworkers or LD workers that the case or provider notes are unlocked.
      3. Provide consultation as needed.
    6. Caseworkers or LD workers who have been notified case or provider notes have been unlocked must document the following in case or provider notes:
      1. The correction date.
      2. What specifically was corrected.
      3. Reasons for the correction.

Forms

FAR Family Assessment (FARFA) DCYF 10-474

Safety Assessment/Safety Plan DCYF 15-258

Structured Decision Making Risk Assessment (SDMRA) DCYF 16-208

Resources

Administrative Incident Reporting policy

Audio Recording policy

Bloodborne Infections Implementation Practices/Procedures policy

Child Care policy

Court and/or Placement Cases

CPS Family Assessment Response policy

CPS Initial Face-to-Face (IFF) Response policy

DCYF Administrative 6.02 Access to Services for Clients and Caregivers who are Limited English Proficient (LEP) policy

DCYF Administrative 6.03 Access to Services for Individuals with Disabilities policy

DCYF Administrative 12.04 Acceptable use of IT Resources and the Internet policy    

DCYF Administrative 13.04 Protecting Privacy and Confidential Information policy

DCYF Administrative 13.06 Records Management and Retention policy

Domestic Violence policy

Electronic Communication policy

Emergency Planning for Children in Out-of-Home Care policy

Family Assessment/Assessment of Progress policy

Family Assessment Response Family Assessment (FARFA) policy

FamLink User Manuals located in FamLink under the Knowledge Web

Family Voluntary Services (FVS) policy

Health and Safety Visits with Children and Youth and Monthly Visits with Parents and Caregivers policy

Intake Process and Response policy

Interviewing a Victim or an Identified Child policy

Licensing Investigations policy

Photograph Documentation policy

Placement Out-of-Home and Conditions for Return Home policy

Records Management policy

Shared Planning Meetings policy