Writing Case Notes Effectively

1. IT’S A DRAG, BUT SOCIAL
WORKERS GOTTA DO IT!
Writing Case Notes

2. Learning goals
• Define case notes in context of good social work practice
• Explain purpose of case notes
• Identify characteristics of well written case notes
• Practice writing case notes

3. Case note writing is a process in which
we document
Interpretations (as
evidenced by) of our
interaction with the
client
Progress
made toward
goals
Interactions
with our
clients

4. Activity:
 What are some problems/barriers to
effective writing narratives/case notes?
 What is needed to write effective
narratives/case notes?
 Why do we keep case notes/narratives in
the case file

5. Definition – Case Notes/Narratives
Case notes/narratives are the
ongoing notes you record about all
activities that are either directly or
indirectly relevant to the client
that contains information
describing the interactions, plans,
and progress of the client during
their relationship with DSS.
How long does it take
for a social worker to
change a lightbulb?
1 minute to change the
bulb.
Then 2 hours to write up
the case notes and
assessment to justify the
intervention.

6. Barriers to writing good
case notes
 Finding the
time
 Completing
case notes too
long after the
event
 Balance
 Worker
attitudes
 Lack of training
 Worker
attributes

7. The guiding principle
Is the information included in your case notes relevant
to the service or support being provided?

8. Good record keeping
(Model for Excellence)
Is a small part of good social work, but careful record keeping
can support your creative thinking and supplement your
ability to help clients make desired changes.
Helps the client and family, the social worker, and the
supervisor meet the client’s goals more efficiently.
Helps the social worker and supervisor meet their
professional goals more effectively.

9. Client outcomes
Poor case notes can
result in poor decision-
making and adverse
client outcomes

10. For our clients ~
good case notes are part of our service to them:
reflecting respect for our clients and the
issues they are dealing with;
acknowledging our responsibility to
them as their service provider; and
honoring the relationship we have with
them, and the lives that they are sharing
with us.

11. If it isn’t
documented,
it didn’t happen!

12. What are case notes used for?
Document visits,
collateral
contacts, service
plans, safety and
protection
Staff to staff
communication
Criminal and
legal
interventions
Validation of
day sheets and
other SIS

13. When writing Case Notes consider:
 What is or is not
appropriate for
agency/protective services
involvement
 Who might eventually
read the Case Notes
 Case Notes (along with e-
mails) can be subpoenaed
 If in doubt, check with
your supervisor.

14. Remember, your
case notes could
end up in a
courtroom!

15. Remember Confidentiality:
Especially with information related to a
customer’s medical condition or disability

16. RAP a short acronym for case notes
Reason for the contact
Action taken
Plan for next meeting/future
action or services

17. Most case notes contain the same
general information
 the personal details of the client
 family history, as appropriate
 type of contact (HV, TC, Face-to-face,
fax, email)
 details of major issues
 action plans (detailing who is
responsible for which action)
 arrangements for the next meeting

18. Example of good case note content
 Met with mom and child in her home. Observed
interaction with child, and mom relayed possibly
trying another childcare option until preschool
services are secured.
 Phone contact to Steve Foster, Attorney, regarding
the status of guardianship change, filing and the
status of the trust. Mr. Foster is preparing the
paperwork for the guardianship change. Anticipates
that filing will be within 30 days through the court.
 Left a voice mail message for Sabrina Jackson head
of community travel to let her know that Fred thinks
that his public transportation suspension is up this
week and if she could look into it. Received a call
back from Sabrina that suspension is up, however,
she suggested that since winter is almost over, to
have Fred remain on board transportation until
spring and then transfer him back to public
transportation.
 Phone call (pc) from Psych. Assistant Justin Smith
(555-8487) about Mary’s revised behavior support
program and new goals. I have not received a copy
yet, so John Smith reviewed the plan with me. He
states that Mary’s self injurious behaviors have
decreased at work but her stealing has increased.
 Justin has separated the target behaviors onto
different data sheets so staff can more easily record
behavior patterns. He has also added an escort for
Mary at work and a pat-down procedure for
stealing. He has gotten the guardians okay for the
changes and has reviewed the new procedures with
staff both at home and at the workshop. I will call
him if I have not received the paperwork by the
beginning of next week and will add the updates to
Mary’s plan ASAP.

19. A well written case note tells a story
 Tells a story from beginning to end that is easy to follow
with no large gaps in the story that leads a reader to not
understand. Writing case notes for a third party not for
self.
 Each beginning entry states the purpose of the intervention
– Make it clear why you are intervening in the person’s life
or making inquiries about their life.
 Describe more than follow-up visit. Explain follow up to
what, to do what, to determine what, to discuss what.

20. Example of an initial entry
 11/7/2017 Adult Protective Services (APS) report received
and screened in for evaluation and assigned to SW Laine
Woodcock. The report alleges that Ms. Smith, 75 years
old, who has dementia, diabetes, and COPD, is being
neglected by her son, John, who is her primary caregiver.
It is alleged that John is refusing to have her medications
filled, to take Ms. Smith to the doctor for her infected feet
and has not provided food that she can prepare so she has
not eaten in several days.
 This sets the stage for other entries.

21. How not to enter follow up interactions
Not this:
 2/2/2018 – SW made a follow-up home visit.
 1/4/2018 – For follow-up SW called the brother.
 12/21/17 – To follow-up, SW called the doctor.
But perhaps this:
 2/2/2018 – SW made a follow-up home visit to discuss
the new plan with Ms. Smith regarding her son. It was
decided that Ms. Smith would continue with the
parenting classes and then would contact the worker for
next steps.

22. Example of a case decisions with
reasons / best thinking clearly stated
 11/10/17 After staffing the case with the Community
Evaluation, a case decision was made to substantiate
caretaker neglect. The findings established that Ms. Smith
was disabled and in need of protective services. Ms. Smith
while not able to perform many of the ADLs and IADLs
and is not fully able to care for herself, has full cognition
and able to consent to services. John, her son and
caretaker also consented to services being provided. Ms.
Smith authorized services.
 11/12/17 SW Woodcock developed a service plan with Ms.
Smith and her son. A copy is in Compass.

23. Be observant
 Be more aware using all of your senses
 What do you see?
 What do you hear?
 What do you smell?
 What do you feel (touch)?
 Who
 Ask questions to clarify.

24. Now for the particulars
 Clear and brief
 Accurate and complete
 Readable
 Written in everyday standard English
 Narratives have no misspelled words and with
acceptable grammar – please!
 Punctuation correct

25. Mechanics of writing good notes
 Verbs
 Correct use of the past tense
 Avoid words with multiple interpretations
 Limited use of contractions
 Not chatty or too familiar
 Make sure to use the correct word when are similar
sounding
 Write in 3rd person when possible
 Use correct word to convey the idea

26. 1. Here
2. Deprived
3. Depraved
4. Would not
5. Hear
6. There
7. They are
8. We have
9. Their
10. Accept
11. Adoptive
12. A lot
13. Already
14. All ready
15. Ensure
More practice with grammar

27. It’s vs Its
 Use it’s only instead of it is or it has.
 In all other circumstances it’s always its (possessive
case)
Examples:
 Thank God it’s Friday.
 He saw its shaggy head and big round eyes
 It’s a cold day today and my dog is scratching its
nose.

28. Punctuation
 Full stops, commas, colons put in writing to assist in
making sense clear.
 Use full stops instead of long sentences.
 Use a comma to indicate to reader that they should take a
breath.
Some of the above course dates may need to be changed if
so adequate notice will be given in these circumstances.
Some of the above course dates may need to be changed.
If so, adequate notice will be given.

29. Use the short word instead of the long
Try Attempt
End Terminate
Start Commence
More Additional
About Approximately
Happened Transpired
Taking Compliance
Showed Indicated

30. Based on facts
 Do you have all the facts?
 Prevents decisions based on faulty
assumptions which allows for
accountability
 Anticipate questions a lawyer
might have
 Is your account black and white?
 Are there any signs of bias?
 Should be objective, not
subjective.
WHO?
WHAT?
WHERE?WHEN?
WHY?

31.  Avoid bias by leaving personal opinions and assumptions out.
 Facts are observations: what you saw, what you heard, and
information that was provided.
 Do not cut and paste an e-mail from another source if it isn’t
objective.

32. Opinions
 Opinion – belief/judgment/interpretation
 Opinions must be acknowledged, informed and
evidence based
Opinion Fact
• He is an alcoholic
• I think she doesn’t love her
mother
• I believe he would be better off
in a facility.
• I smelled alcohol on his breath
• She stated that she didn’t love
her mother like a daughter
should.
• His doctor completed an FL-2
indicating in his professional
opinion he should be placed
out of his current situation.

33. ALERT!
If your case notes include (or could
include) these phrases—your case notes are
your own opinions, not facts.
“I think”
“It is my
opinion”
“It seems to
me”
“I assume”
“Probably”

34. No diagnoses
No clichés
No street talk
No Stereotypes
No personal
opinions
No prejudices

35. Example of using street talk or too casual
SW tell the clients nurse why she was out there. Client nurse said thank
god you come out here. The client nurse said these kids really need some
help. SW said what’s going on sis? The client nurse said the kids not been
taken care of. SW said “yeah man, that’s what seems to be happening.”
The client nurse said caretaker don’t stay home with the kids. Caretaker
is the mother of the client. Client can’t function too good. Client nurse
said caretaker don’t see the kids as much. Caretaker has a boyfriend.
Client shares a room with 3 other sisters. Client is not from the USA.
Wow.
SW called 919-555-0000. Caretaker picked up the phone. SW introduced
self to caretaker on the cell. SW told caretaker why she was giving her a
call. Caretaker was upset and crying. Caretaker said none of that stuff is
true and that she always be at home. SW said “yeah, I understand.”
Caretaker told SW she will call her back.

36.  K Goat
 H Woke
 J Basic
 I Bye Felicia
 G Bae
 D On point
 F Dead
 C Sips tea
 A Salty
 E Fam
 B Throw shade
Activity
Matching slang words

37.  Use third person
pronouns as singular
 Use third-person plural as
plural
 Second person pronouns
– plural
 Second person pronouns
as singular pronoun
 Venacular – used for both
singular and plural
 they/them/their/themselves
 they/them/their/themselves
 You/your/yours
 Thee/thy/thine !
 You-all/youse/ya’ll
Non – gender specific pronouns

38. Social
Work
Jargon
&
Acronyms

39. Service Plan
 A common problem in case notes is
that the plan/goals seems to be an after
thought.
 Your case notes should be thorough
enough that a coworker could step in
for you and know how and what you
are planning to work on next and what
has been completed.

40. The next steps needs to include:
Think of your plan as next steps or
operationalizing your playbook
 The date of your next intervention
 Issues to be discussed with either
the person or collateral sources
 Any changes to the current focus of
services

41. Example of describing a plan
 Instead of: The plan is to meet with the client.
 The case note is better written like this:
Plan to meet with the client and his wife on
4/25/2017 in order to help his wife understand and
cope with the client’s depression. SW will contact
the client’s health provider, Dr. Smith, to coordinate
care. SW talked with the client and his wife about
his safety plan. SW will call the client tomorrow
and will provide transportation to his mental health
appointment.

42. Include in the case activity:
 Any correspondence via fax, email, pertinent voice mail
recordings, audio recordings, medical reports, mental
health assessments, relevant photographs that are
uploaded are documented in the narrative.
Note: Audio recordings should be identified as to the date
and time of the recording, permission or awareness received
to record the conversation, all of the voices on the recording
identified by name and title and the purpose for the
interview.

43. Questions about your own notes
 Question – think about the case notes you are currently
writing. Would they be useful to another case worker if you
were to leave the organization? Do they give an accurate
picture of the client's history and current situation?
 Question - Can you think of ways in which you could write
better case notes than the ones you are currently writing?
We will make a list as fast as we can with each
person calling out a response.

44. Immediate
documentation
Case notes should
be written as soon
as possible after
the contact,
meeting, situation
or incident occurs- use
your iPads!
Paperwork completed
within 10 days of making a
case decision.
.

45. E G G T I M E R M E T H O D
Egg Timer

46. Program your playlist for
success

47. Structure your notetaking for
ease of writing later

48. Treat yo self!

49. Prioritize and triage
most urgent

50. Revisit your structure

51. Build on previous successes

52. Time for a break

53. Get comfortable

54. In the zone

55. More is
not
always
better
BETTER
IS
BETTER!

56. Presentation: Quality over quantity, shedding
fluff whenever possible and having coherence.
Direction: The writing task has a purpose (e.g.
to inform, remind, document, etc.)
Ethics: A subjective narrative that has facts
(i.e. things we observed) that are supported
with evidence.
When you have an opinion or suspicion, you
state it (e.g. “It is this the worker’s belief that
[x], as supported by [y].”)
Adhere to these rules

57. Equal and balanced
Quality
Social
Work
Case notes
PracticeTraining

58. • Defined case
notes in context
of good social
work practice
• Explained
purpose of case
notes
• Identified
characteristics of
well written case
notes