How to Write Better Case Notes (Part 3)

How to Write Better Case Notes Part 3

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

Client: Joe
Date: 4/15/15
Session #5

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.

 

Client: Joe
Date: 4/29/15
Session #6

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.

social work case notes

 

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.

Client: Suzy
Date: 2/1/15
Session #3

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.

 

Client: Suzy
Date: 2/8/15
Session #4

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

How to Write Better Case Notes (Part 1)

How to Write Better Case Notes (Part 2)

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.

7 Comments

  1. Kristy's Gravatar Kristy
    November 19, 2016    

    As a graduate intern, these are very helpful in knowing how to write better case notes. I struggle with knowing what I should include and not include and use S.O.A.P. notes as my guide. I tend to write more subjective info than objective, but this give me a clear idea of what I need to write for sure!

    • Robin W's Gravatar Robin W
      April 13, 2017    

      This is new to me. I just had an interview for a position and one of the criteria’s was to write a case note. I have never done one before, but have written habilitation notes. They are not so in-depth as case notes. This page was very helpful in helping me to see what I should or should not do. However an acronym was mentioned from a previous comment and I don’t know what it stands for, can you explain. S.O.A.P.

      • Evelyn Gimarino's Gravatar Evelyn Gimarino
        August 29, 2018    

        S.O.A.P
        S – Subjective/Summary statement by the client
        O – Objective datat/information that matches the subjective statement
        A-Assessment of the situation, the session & the client, regardless of how obvious it might be based on the subjective & / objective statements
        P- Plan for future clinical work

  2. Charlotte's Gravatar Charlotte
    July 31, 2018    

    My major is Social Worker and I have a heart for it. I feared to be a social worker because of case management. The job application asks to demonstrate excellent case management writing skills. Reading the example of your case notes, I believe it would be helpful. What do S.O.A.P. means and could you provide an example.

    • August 1, 2018    

      SOAP stands for subjective, objective, assessment, and plan. I don’t have an example handy, but I’m sure you can find one online. Most employers have a particular format they want used for notes.
      Best wishes for your career decisions,
      Sharon

  3. July 2, 2019    

    I would like to have a conversation with you about passing the LCSW.

    • July 2, 2019    

      Thanks, Maude. I doubt I would be much help, though. It’s been 20 years since I took the exam!

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