Child Welfare Academy Competency Exam Practice

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In case record, when you have an opinion that the client was under the influence, how should you document it?
Correct Answer:
Clearly document why you have this opinion.
Explanation:
Clearly documenting why you believe the client was under the influence is essential. In case records, your opinion should be grounded in specific observations and the reasoning that connects those observations to your conclusion. State exactly what you observed (for example, odor of alcohol, slurred speech, unsteady gait, inconsistent or impaired responses) and when and where it occurred. Explain how these indicators lead you to conclude impairment, and keep the language tied to your professional judgment rather than presenting it as an undisputed fact. If there are other explanations or uncertainties, note them and indicate whether you sought or recommend additional evaluation or collateral information. When you document this way, the record stays accurate, supports accountability, and helps others understand the basis for decisions and safety planning. Avoid presenting opinions as unconditional facts without backing, and refrain from including unverified hearsay without proper attribution and assessment.

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