Child and Family Services Policy > Section XIII - Case Records > XIII. C. OCFS Child Welfare Documentation Policy

I.SUBJECT

Office of Child and Family Services (OCFS) Child Welfare Documentation Policy

II.PHILOSOPHY

Documentation of case activities is critical in ensuring state and federal timeframes are met, sound decision making is occurring, and the proper intervention methods are being utilized. This policy will instruct staff on how various interviews, observations, activities and updates are to be entered into the Maine Automated Child Welfare Information System (MACWIS). This policy will provide instructions on when, where, and what information is to be entered.

III.PURPOSE

OCFS Child Welfare staff is responsible for documenting the work that they do with families. Assuring the safety, permanency and well-being of the children they serve. Documentation entered into MACWIS is to demonstrate that social work staff are having purposeful contact with families, timeframes are being adhered to, progress is being made throughout the life of the case and when closing a case, and the reasons why a family is no longer in need of OCFS intervention.

IV.PRACTICE MODEL

How we do our work is as important as the work we do – As we work with children, families and their teams, we clearly share our purpose, role, concerns, decisions, and responsibility.

V.LEGAL BASE

Title 22 R.S. § 4004

VI.DEFINITIONS

Narrative Log: Primary MACWIS module for documentation of contact with case members.

Critical Case Members: The child/ren identified as potential victims and victims of abuse and neglect, and the primary caregivers responsible for the child/ren’s care.

Case Member: Individuals involved in the case, including but not limited to; out of home parents, other children in the home, other household members, and service providers for the child or family.

Collateral Contacts: Communication with individuals involved in the case that are not critical case members.

Resource Parents: Families that care for children in departmental custody.

Family Share: Meeting between parent/caregiver and resource parents within 5 business days of a child’s move into a new placement.

VII.PROCEDURE STATEMENT

Narrative entries are to be entered within 10 calendar days of the occurrence.

Amending Documentation: The narrative log may be amended at the request of a supervisor, if the entry was either inaccurate when made or has some significant grammatical or reporting errors. The social worker will not change the original entry, but rather add to the original entry with a notation that the entry has been amended on the date and time of the amendment entry, followed by the amendment information. In exceptional circumstances, the Director, or designee, of Child Welfare Services can approve the removal or modification of a narrative entry, in consultation with the Division Chief, or designee, of the Child Protection Division in the Office of the Attorney General.

The following is a list of events that require documentation in MACWIS in the main narrative module:

•Face to face contact with:

oAll persons responsible for the child/ren whose interviews will provide a basis for any and all findings that are reached during an assessment of alleged child maltreatment.

oChildren, including child’s level of safety, well-being and permanency. All interviews that require fact finding interviews due to allegations of abuse or neglect will be audio recorded; these recordings will be stored on the v-drive. A summary of the audio recorded interview will be entered into narrative.

oAll persons responsible for a child, including behavior changes to reduce risk and identified signs of danger. Address participation and active efforts related to current plan, unmet needs, and plan to address unmet needs.

oOther household members, including their role in the child’s life, the strengths and challenges they have regarding the family.

oResource Parents, including their ability to provide quality care for the child, any unmet needs of the child or resource parents, and how these needs were addressed.

•Collateral Contacts, including information regarding safety, well-being and permanency for the child. Addressing critical case members progress toward reducing jeopardy and identified signs of danger.

•Family Team Meetings (FTM) and Facilitated Family Team Meetings (FFTM), staff will complete the FTM Summary Report which is entered in the primary narrative module; the paper copy is kept in the hard file. The plan developed will be entered into the MACWIS module plan list.

•Preliminary Safety Decision.

•Relative Resources is to be completed as outlined in the decisive factors checklist (addendum) and updated with every new child plan.

•Summary of court events including who retains custody of the child.

•Emails and texts relevant to safety, well-being, and permanency (see email confidentiality protocol).

•Background checks, summarize details relevant to safety, wellbeing and permanency.

•Telephone calls, multiple telephone call attempts can be entered under a single narrative log entry.

•Note evaluations/reports with brief summary received and location in hard file.

•Family Share Meetings, summarize significant outcomes.

•Visitation Decisions are to be entered by supervisor every three months or sooner as necessary or when there are changes.

The following is a list of events that are documented in MACWIS in the secondary narrative module. All information in MACWIS, including information in the secondary narrative, may be part of discovery in court cases.

•Adoption split including base case number

•Affidavits

•Jeopardy Statement

•Immediate Risk Statement

•Social Summaries

•Kinship Assessments

•ICPC Home Studies

•Requested Disposition

•TPR Summary of Facts

•Transfer Summary

All Child Welfare social work done by OCFS staff is to be documented into MACWIS. Records gathered from other sources are to be stored in the family’s case file or the child’s case file and organized according to the case file cover sheets.

Documentation for narrative entries will be written in a behaviorally specific, non-judgmental manner and done in the first person. Documentation will be a clear, concise, and factual summary of events.

Social workers are to ensure that the MACWIS modules are completed and updated according to the type of case they are working on.

•Medical Passport including all medication changes and medical appointments

•School

•Plan List includes all plans created with the family and/or the child/youth

•Visit Plan choose the plan module on the primary toolbar then the visit plan module on the secondary toolbar to document the visit plan

•Placement will be updated on the same date placement change occurs

•Special Needs

•Demographics

•NYTD screens