How to Write Better Case Notes (Part 2)

How to Write Better Case Notes Part 2

 

Writing case notes is a struggle for most social workers and therapists. They’re time-consuming and generally a drag to write. However, learning how to write good social work case notes will protect both you, your employer, and your client. The more skilled you are at writing case notes, the faster they will go. This edition of How to Write Better Case Notes focuses on the plan.

 

A common problem with writing case notes is that the plan seems to be an afterthought. Often the plan is just the date of the next session. Sometimes the plan is left out altogether. Your case notes should be thorough enough that a coworker could step in for you in an emergency and know-how and what you are planning to work on in the next session.

 

Examples of case notes with incomplete plans:

  • The plan is to meet with the client next on 4/27/15.
  • The plan is to continue to support the client with his goals.

 

The plan should include:

  • The date of the next appointment.
  • Issues to be discussed at the next session.
  • Any changes to the current focus of treatment.

 

Here are examples of complete plans in case notes:

  • Plan to meet with the client and his wife on 4/24/15 to help his wife understand and cope with the client’s depression. The writer will contact the client’s psychiatrist to coordinate care. The client will complete a daily mood log and bring it to the next session.
  • Plan: The client will utilize resources and strategies in her safety plan. The writer will contact the client by phone tomorrow, 4/21/15, at 10 am to monitor and re-assess the client’s suicidal ideation. The writer and client will meet for a session on 4/22/15 at 10 am to monitor and re-assess the client’s depression and suicidal ideation and continue to work on the goal of the client using safe coping strategies.

 

I hope that improving the plan section of your notes will help you to work more effectively with your clients. The plan not only documents the date of the next session but planned interventions or issues to be addressed. Properly documenting this will help you stay on track with your treatment goals and the client’s progress.

 

Please leave a comment and let us know what other struggles you have with case notes or documentation. We’d love to support you with information to improve your case notes and record-keeping.

 

More about writing case notes

How to Write Better Case Notes (Part 1)

How to Write Better Case Notes (Part 3)

8 Tips to Complete Your Social Work Documentation

 

 

©2015 Sharon Martin, LCSW
Photos courtesy of Canva.com

Sharon Martin has a passion for clinical supervision, mentoring new social workers, blogging, and reading all things social work related. She is a California Licensed Clinical Social Worker with over 20 years in the field. Sharon has worked extensively in Bay Area non-profits and successfully runs a private counseling practice in San Jose. Sharon writes regularly for PsychCentral and the Good Men Project. She's also the author of The CBT Workbook for Perfectionism.

3 Comments

  1. LaToya's Gravatar LaToya
    November 19, 2018    

    This information was very helpful and has allowed me to complete my documentation of my sessions a bit faster.

  2. Anna Reuter's Gravatar Anna Reuter
    January 8, 2020    

    This was very helpful! Thank you for posting.

  3. Desiree's Gravatar Desiree
    February 28, 2020    

    This was very helpful, thank you. I was hoping to find good examples of case notes.

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