How to Write Better Case Notes:
The Importance of Sequential Tracking
Case notes are 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 importance of sequential tracking. By this, I mean documenting sequential client contact and progress.
As a clinical supervisor, lack of a consistent line of treatment is another issue that I frequently see in case notes. Let’s look at some examples.
Missing Notes, Lack of Follow-up, Clinical Issues Left Hanging
Example 1: Joe
Met with the client for his regularly scheduled case management appointment. The client presented with anxious mood and labile affect. He was neatly dressed and hygiene was good. Provided psycho-education about medication compliance. The plan is for the client to purchase a pillbox and set an alert on his phone to increase medication compliance. Next session scheduled for 4/22/15.
Met with the client for his regularly scheduled case management appointment. The client presented with an anxious mood. The client seemed preoccupied and thinking was tangential. He was neatly dressed and hygiene was good. Assisted the client in identifying worries and cognitive distortions. The client gained awareness of his all or nothing thinking. For homework, he will record cognitive distortions daily. Next session scheduled for 5/5/15.
It should be obvious that several things are missing from this client’s notes. The first problem is there is no note for 4/22/15. Whenever you have contact with the client planned, there must be a note for that date. We are left to wonder: Did the client cancel? Did the therapist cancel? Did the client not show up? It is tempting to leave out all the short phone conversations, messages or emails received. And at the time, a client canceling may not seem like it is significant. The problem is that we really don’t know what is clinically significant until further into treatment. I’ve seen situations where clinicians want to discharge clients after frequent no-shows or cancellations, only to find it has only been documented once or twice.
Remember the cardinal rule of case notes: “If it’s not written down, it didn’t happen.”
The second problem with Client Joe’s chart is that note #6 makes no mention of the issues and interventions used in session 5. Think of it as the plot of a novel. Don’t leave the reader hanging. It’s good clinical practice to follow-up on the issues, intervention, plans, and homework. You should document whether Joe got the pillbox and used his alarm and whether he is taking his medications as prescribed.
Case notes should tell a comprehensive and sequential story of your client contact and progress.
Example 2: Suzy
Now for the second example of notes without adequate sequential tracking. This one has more serious consequences.
The client presented with depressed mood and flat affect. Assessed symptoms. The client indicated that she has persistent suicidal thoughts about overdosing on her medications. Created a safety plan with the Client. The client was receptive and agreed to attend an AA meeting tonight, talk with her sponsor, and have her mother hold her medications. The plan also states that this writer will call the client tomorrow at 9 am to re-assess suicidal ideation.
The client presented with depressed mood and blunted affect. Assessed the client’s symptoms. She continues to have a depressed mood, insomnia, loss of appetite and pleasure. The client denied suicidal ideation. She stated that she’s been attending AA meetings daily since the last session and finds the support and socializing helps her depressive symptoms. The plan is for the client to continue attending AA daily, see the psychiatrist on 2/10/15 and meet with the writer next on 2/15/15.
This series of notes has serious deficits. Again, the writer failed to document whether he did the planned follow-up (phone call to monitor suicidal thoughts). On an issue as serious as suicide, it is imperative that you document that you adequately assessed and treated your client. This chart shows a failure on the therapist’s part to adequately do this.
I hope that these examples reinforce the importance of documenting all of your client-related work and that there is a documented progression of treatment.
More about writing case notes
©2015 Sharon Martin, LCSW
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