Strengthening Healthcare Social Work Documentation to Mitigate Bias

Healthcare social workers engage in discipline-specific, skilled interventions informed by training, best practices, and attunement to social justice. Documenting assessments and interventions clearly communicates the value of the social work perspective, skills, and contributions and influences outcomes while also contributing to the learning of those who read our work. This class will review the literature on bias in documentation in the medical record, a focus driven by the advent of “open notes” as of April 2021. Sample patient notes and narratives will be used to illustrate how social work documentation communicates best practices and has the potential to mitigate bias while integrating the impacts of social determinants.

No matter the setting, word choice is foundational to communication and documentation and significantly impacts patient family experiences, decisional outcomes, bereavement, and legacy. We will explore attributed meanings underlying words and phrases used in health care and unintended consequences. Our spoken words are often reflected in the written words and phrases used in documentation in a medical record, which is a permanent record influencing care. This class will expand on language and word choice and highlight the ethical responsibility in documenting authentically and with the awareness that documentation is permanent, creates opportunities to mitigate bias, and can maximize the impact of the social work lens of “person in environment.”

Completion of this class will result in the receipt of two continuing education hours.