Documentation as part of substance use rehabilitation: how workers account for the significance of documentation during interviews

Abstract

PurposeThe focus of this article is in documentation in substance abuse inpatient rehabilitation. Our article scrutinizes how workers give accounts of the documentation in the inpatient substance abuse rehabilitation unit and what kind of client information the workers record.Design/methodology/approachThe study focuses on institutional interaction and practices. Our data consist of interviews with substance abuse rehabilitation professionals (N = 15). We analyzed the interviews using content analysis and the account concept in keeping with the ethnomethodological research tradition.FindingsStudy shows how workers account for the significance of documentation. Workers deemed documentation significant in four different ways: in gathering basic and rehabilitation information, in storing and transmitting information, as a tool for analysis and assessment and in supporting linguistic transparency in substance abuse rehabilitation. Workers justified the significance of documentation by the legal requirement to record information about clients. Documented information enables clear management of client information and supports substance abuse rehabilitation work in various ways. Documentation contains descriptions of the client’s situation and work performed. Additionally, documentation serves as a tool for communication among social care professional.Originality/valueThus the research show that documentation plays a significance part in the inpatient substance abuse rehabilitation and are connected to its institutional tasks and practices.