Writing case notes is a key skill for all social workers to cultivate. Thoughtful, factual case notes document a client’s symptoms and progress, and can help govern treatment decisions. Research shows that good case notes can even improve treatment outcomes and expedite progress. Many clinicians must also use case notes for billing purposes, as part of their job requirements when working for an agency that gets government grants, or to document care in the event of an insurance audit. Yet writing case notes can be tedious and frustrating, especially to social workers who feel overworked.
Here’s how you can write better, more effective case notes without wasting time.
Schedule Time for Case Notes
Case notes become more frustrating when they’re something you have to fit in on top of a busy day. Instead, incorporate them into your daily schedule. Make case note review and writing a part of each session. Schedule 10-15 minutes after each session to draft notes while the session is still fresh. This ensures accuracy and affords you a chance to reflect on the session or make notes to yourself for the next session.
You should also schedule 10-15 minutes before each session to review the notes from previous sessions. This ensures you don’t forget key pieces of information, thereby improving your relationship with your clients and your treatment recommendations. It can also help guide the session, and ensure both you and your client stay focused on treatment goals.
Use Case Notes to Plan for Treatment Sessions
Effective treatment builds upon itself. Treatment notes help you remember homework assignments, recall challenges the client was facing, and maintain a more objective approach in treatment. You can memorialize strategies that worked and those that did not, while monitoring progress over time. This can help guide treatment sessions and make it easier to discuss treatment goals with your client.
Know What to Write
Particularly if you must fill out forms your employer designs or meet case note requirements for insurance billing, it’s easy to view case notes as nothing more than busy work. You might feel like you just need to get a certain number of words on the page. But well-written case notes are a valuable practice tool. These strategies can help make your notes more effective:
- Write down information that will help jog your memory for the next session. Emphasize the most important information you discussed, as well as any homework you assigned or plans you made for your next treatment session.
- Keep case notes objective. “Patient seemed anxious” is not objective. “Patient expressed fears about the future, was shaking, and said she was having panic attacks” is more useful information.
- Leave out unnecessary details and filler.
- Note a client’s appearance or outfit only if it is relevant to their treatment. Avoid value judgments. “Provocative” dress is a subjective judgment that provides little value. A note indicating that a client has stopped wearing clean clothing or that their clothing is looking progressively more damaged, however, may be relevant.
- Be mindful of your own perceptions and biases. Don’t say that the client was aggressive or combative. Instead, itemize the specifics of each interaction. For example, “Client expressed distrust of their therapist, and said they wanted to try a different treatment plan.”
- Avoid dismissive, emotional, or judgmental language. Don’t call a client hysterical, difficult, or disheveled.
- Note important biopsychosocial information about the client, such as recent medical diagnoses, the people with whom the client lives, any family history of illness, and the presenting issues that caused the client to seek treatment.
- Outline the treatment strategies you are using with the client. Be sure to note outcomes over time, as this can help you assess the effectiveness of treatment and track your own compliance with the treatment plan. Many clinicians find that listing the specific treatment plan they are using helps them stick to this treatment plan and avoid distraction.
- Document any legally-relevant information, especially if any aspect of treatment presents liability to you or the client. For example, if the client indicates a desire to harm themselves or others and you must notify a third party, indicate the nature of the threat and note whom you notified and how.
Keep Case Notes Secure
Case notes contain highly sensitive information about your clients—their symptoms, fears, conflicts and treatment goals, as well as their diagnosis and treatment history. Like other medical records, treatment records are protected under the Health Insurance Portability and Accountability Act (HIPAA). So you must store them in a secure fashion.
The safest option for storing treatment notes is to keep them in a password-protected, encrypted cloud storage system. Do not access these notes over an unsecured server, such as a public network in a coffee shop. Avoid writing down passwords, giving the password to third parties, repeating passwords, or using easily guessed passwords such as your name or birthday. Physical security is also important, especially if you keep your passwords saved on your computer. Lock any computers or other devices on which you store treatment notes, and consider adding a feature that enables you to wipe your device if someone steals it.
It’s also important to protect case notes from third parties who may use the legal system to gain access. A social worker’s obligation to hand over case notes in response to a subpoena varies from state to state, and may also depend on the subpoena itself. Keeping case notes that are useful but sparse can help you balance your client’s privacy needs with treatment goals in the event that you are legally required to hand them over. For example, rather than detailing every aspect of a fight with their spouse, you might only note that the client had a fight with their spouse, or that it follows an ongoing pattern.
GoodTherapy supports clinicians at every stage of their career to deliver quality, ethical therapy. Our continuing education webinars help you master a wide range of skills, including writing case notes. Members also gain access to our directory, and can even contribute to our popular blog. Join today to get listed!
- Case notes. [PDF]. (2016). Retrieved from https://www.aasw.asn.au/document/item/2356
- Martin, S. (2020, January 7). How to write better case notes (Part 3). Retrieved from https://socialworkcoaching.com/how-to-write-better-case-notes-part-3/
- Merovich, A. (2015, December). 315: Writing skills for case documentation. [PDF]. http://www.pacwrc.pitt.edu/Curriculum/315WritingSkillsforCaseDocumentation/Content/ParticipantsGuide_eln_am_12-21-15.pdf
- Wohltmann, T. (2017, January 19). Intro to case notes for new social workers. Retrieved from https://www.oercommons.org/authoring/8157-intro-to-case-notes-for-new-social-workers/view