If a colleague has ever faced a professional lawsuit, you likely heard them either lamenting their note-taking habits or thanking the stars for them. Writing effective case notes (a.k.a. progress notes) for social work serves more than the purpose of record-keeping, however. Yes, detailed notes are necessary to satisfy legal requirements, but notes are an invaluable part of the therapy process itself. Because treatment never follows the same path from client to client, it’s nearly impossible to retain important information and insights from each session. Case notes act as a shorthand account of the client’s journey, providing a reference when you need it. In this post, we look at the information that should be included in your case notes and tips for how to present the content.
Benefits of Writing Good Case Notes
Keeping detailed case notes is worth the extra attention needed to make them effective for several reasons. Here are just a few of the benefits of good case notes.
They help you and the client stay focused on the goals of treatment — When treatment spans a series of months or years, it’s easy to forget why you’re doing what you’re doing. New goals may present themselves, and you and your client may reach other goals in the process. Good case notes help you and your client keep your eyes on the main goals and ancillary goals of treatment.
Tracking client progress keeps you and your client motivated — Seeing progress makes the hard work worth it, for both you and your client. Be sure to celebrate small wins and milestones.
The process of writing case notes helps to boost creative thinking around treatment options — The act of writing something down, whether electronically or on paper, helps you to focus on the issue at hand. This focus can help spur problem-solving and help you come up with ideas for treatment.
They allow other professionals to step in as needed with an understanding of the ground you’ve covered with a client — Often, you’re working as part of a client’s team of healthcare and mental health professionals. Your notes can help these other professionals work more effectively.
Proper attention to case notes honors the relationship built between you and a client — Rushing through the process of creating case notes or taking shortcuts can put you in a frame of mind that isn’t respectful to your relationship with your client. While you don’t need to waste time on unnecessary details, devoting the necessary attention to write a good case note that will serve its purposes will honor the relationship.
Detailed case notes can protect you in court — If you ever receive a subpoena, you’ll be grateful for taking good case notes. Detailed notes will prove that you did your professional best and abided by rules and regulations.
Information to Include in a Case Note
The guiding principle for writing effective case notes is to include content relevant to the service(s) or support provided. The specific content will vary based on your specific situation, but AASW broadly recommends the following:
- The biopsychosocial, environmental and systemic factors impacting the client, including the client’s culture, religion/spirituality
- Risk and resilience factors
- Facts, theory or research underpinning an assessment
- A record of all discussions and interactions with the client and persons/services involved in the provision of support including referral information, telephone and email correspondence
- Arecord of non-attendance (by either you or your client) at scheduled and agreed meetings or activities
- Evidence that you and your client have discussed your respective legal and ethical responsibilities — such as client rights and responsibilities, informed consent, confidentiality and privacy, professional boundaries, freedom of information, etc.
In addition to these broad guidelines, experts also recommend including the following specific pieces of information in each case note:
- Topics discussed during the session
- How the session related to the treatment plan
- How the treatment plan goals and objectives are being met
- Interventions and techniques used during the session and their effectiveness
- Clinical observations
- Progress or setbacks
- Signs, symptoms and any increase or decrease in the severity of behaviors as they relate to any diagnosis used
- Homework assigned, results and compliance
- The client’s current strengths and challenges
Additionally, HIPAA requires that the following be included in case notes:
- Demographic information
- Prognosis and treatment plan
- Progress to date
- Dates of service
- Who attended the sessions
- Financial issues (billing, costs, payments, etc.)
This may seem like a lot of information to present, but case notes with this data will help document not only what took place in the session, but also your decision-making process and how you implemented treatment and intervention.
How Notes Should Be Presented
Of course, the information recorded about a client and their treatment should be accurate, impartial, and complete, and should exclude any emotive or derogatory language. If you offer a subjective opinion, be sure to include the relevant theory behind the opinion, background information, and research to support it. And you’ll want to share only relevant details — those related to the treatment. It’s also a good idea to limit social-work jargon when possible and replace complex words with similar, easier words.
There are several different formats you may want to consider using to help organize your notes. There are four popular formats that are easy to follow.
- S.O.A.P. (Subjective, Objective, Assessment, Plan)
- B.A.R. (Behavior, Action, Response)
- D.A.P. (Data, Assessment, Plan)
- S.T.I.P.S. (Signs and Symptoms, Topics of Discussion, Interventions, Progress and Plan, Special Issues)
- B.I.R.P. (Behavior, Interventions, Response, Plan)
It’s helpful to review your notes after writing them to make sure they’re clear and direct and that the words you’ve used don’t leave opportunity for multiple interpretations.
Regulations Around Case Notes
Regulations relating to case notes vary by state, so you’ll want to be sure you understand those governing your location. For example, some require that you keep case notes on file for several months, while others require several years. Each state has rules around how notes should be managed. And some states have made modifying case notes after the fact illegal (with the exception of noting after the fact if a session turned out to be the final one with a client).
Documenting in detail the path you take with a client delivers benefits. Because case notes have such a big impact on the efficacy of social work and the health of a practice, focusing on taking good notes is time well spent.
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