> For the complete documentation index, see [llms.txt](https://fieldworker.gitbook.io/fieldworker-docs/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://fieldworker.gitbook.io/fieldworker-docs/fundamentals/concepts/case-note.md). # Case Note Well-written case notes provide objective descriptions grounded in fact and evidence, and leverage a social worker's assessment and opinions without bias. ### What are case notes? Sommers-Flanagan (2009) suggests that case notes reflect the information provided in an interview and usually cover the following three broad areas: 1. Identifying, evaluating, and exploring the client's chief complaint and associated therapy goals. 2. Obtaining data related to the client's interpersonal style, interpersonal skills, and personal history. 3. Evaluating the client's current life situation and functioning. The information recorded about a client should be impartial, accurate, and complete, with care taken to ensure that: * Only details relevant to the provision of a support or service to which the client has consented are recorded * When working with involuntary clients, this means recording information relevant to statutory practice * notes are free from derogatory or emotive language * subjective opinions are qualified with relevant background information, theory, or research {% hint style="success" %} ## **Case notes cheat sheet** To make the Case Notes Cheat Sheet truly useful for case managers—moving it from a simple list to a practical decision-support tool—it should be organized by the "workflow of a visit." Instead of just listing what to record, this version provides trigger questions to ensure documentation is objective, compliant, and audit-ready. #### 🛠️ The Ultimate Case Manager’s Cheat Sheet *Use this guide to ensure every* [*Case Note*](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) *tells a complete, objective, and goal-oriented story.* #### 1. The Setup (Administrative Context) * The Log: Precise Date, Start Time, and End Time. * Method: Was this Face-to-Face (Home/Community) or via Telephone/Video? * The Circle: Who else was in the room or on the call? (e.g., Guardian, Provider staff, family member). * Purpose: State the primary reason for contact (e.g., "Monthly Monitoring," "ISP Revision," or "Crisis Intervention"). #### 2. The Evidence (Objective Observations) * Environment: If on-site, what did you see? Is the home safe? Are there adequate supplies/food? * Presentation: How is the person today? Note mood, hygiene, and physical health (grounded in fact, not judgment). * Direct Quotes: Use the person’s own words when discussing their satisfaction or goals. This ensures their "voice" is at the center of the record. * Decision-Making: Did the person appear to understand the topics discussed? Note their ability to make informed choices. #### 3. The "Why" (Professional Analysis) * Goal Progress: Refer specifically to the ISP/Plan. Is the service being delivered? Is the person moving toward their outcomes? * Health & Safety: Document any new medical issues, falls, or medication changes since the last contact. * Risk Identification: Are there any new barriers to their independence or safety? * Consultation: If you spoke with a doctor, the DDD, or a therapist, document *why* you reached out and what was decided. #### 4. The Result (Action Plan) * SC Interventions: What did *you* specifically do? (e.g., "Advocated for increased hours," "Provided list of local transportation providers"). * Assigned Tasks: Who is responsible for the next step? (e.g., "Guardian to schedule dental appt by 5/1"). * Follow-Up: Set a clear expectation for the next contact or monitoring visit. #### 💡 Quick Tips for "Audit-Ready" Notes > Avoid Emotive Language: Instead of "The client was angry," write "The client raised their voice and stated, 'I am not happy with this provider.'" > > Focus on Fact: Don't assume. Instead of "The house was a mess," write "There were four bags of trash in the hallway and unwashed dishes in the sink." > > Use Frameworks: If your agency prefers a specific structure, try the [SOAP or BIRP](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) methods to keep your assessment separate from your observations. > {% endhint %} Several different formats exist for writing case notes. 1. S.O.A.P. (Subjective, Objective, Assessment, Plan 2. D.A.P. (Data, Assessment, Plan) 3. B.I.R.P. (Behavior, Interventions, Response, Plan)
SOAP (Subjective, Objective, Assessment, Plan) These four sections try to ensure case notes are complete, yet concise. * Subjective: What the client says about the problem; opinion-based information from the client including their goals, concerns, feelings, and perceptions of their problems. Also, include relevant information from other family members or close friends. * Objective: Information that is fact-based, verifiable, and quantifiable. This can be direct observations of the client. This might include things like the client’s appearance, body language, and other obvious behavior. * Assessment: Using subjective and objective information to assess the situation; a conclusion or recommendation could be included, with evidence as to why conclusions have been drawn. * Plan: The plan of action, e.g. referrals to other agencies, goals, timeline targets, i.e. the steps to take to assist the client in meeting their needs
DAP (Data, Assessment, Plan) The Data heading covers everything that occurred during a counseling session, including but not limited to a client’s observable responses, affect, traits, and behavior. This section includes specific, objective information about the session’s focus, what was said, and more, in order to answer the question: “What did I observe?” Under Assessment, social workers interpret and analyze the data in the previous session. This involves applying some professional subjectivity and may result in clinical hypotheses or findings. Here, social workers might record things like how a session related to a client’s overall treatment goals, a working hypothesis, and/or a probable diagnosis of a client’s condition. The Plan section is used for making decisions and recommending a plan of treatment for the client. Here, the objective and subjective data from the previous two sections are used to inform a social worker’s strategy or next actions – often between the current session and the next. This could include recommendations for therapy or lifestyle changes, among other short- and long-term treatments.
BIRP (behavior, Intervention, Response, Plan) **Behavior** (Presenting the Problem) This section records the subjective and objective details that were observed (CF SOAP outline above). This section can also contain details about the session itself, such as where it took place. * Example: Met with client X in the office. The most recent assessment shows they are presenting symptoms of anxiety. Today they showed signs of exhaustion, lack of focus, and looked tired. They reported not being able to sleep in the past week and feeling overwhelmed by work. **Interventions** This section outlines the methods used to reach the goals and objectives of the therapy. It’s a concise summary of the conversation, focusing strongly on the therapist’s actions and the patient’s reactions. * Example: Through client-centered techniques, this writer encouraged the patient to expand their thoughts about their work. Negative thoughts were identified and challenged. The patient was asked to see if there is a link between their insomnia and the stressful period at work. The connection was successfully made and normalized through discussion. The conversation then focused on the specific work-related triggers that may have led to insomnia. A mild sleep aid was prescribed. **Response** In this section, the therapist should record the client’s response to the intervention, including what the client said and how they reacted. * Example: The patient initially rejected the link between their insomnia and stress at work. When asked how work made them feel, the patient became silent, reduced eye contact, and disengaged from the conversation with the writer. After a few moments of thinking, the patient was able to describe their feelings about their work. **Plan** The plan outlines when the next session will take place and its focus. * Example: The next appointment scheduled for September 16, will assess the client’s response to the sleep aid and reassess their feelings about work.
### Historical Audit Log (Main Feed) The central part of the screenshot features a chronological feed of entries, resembling a messaging thread. This provides a transparent history of client interactions: * Timestamp Headers: Entries are organized under specific dates (e.g., 09/18/2023), allowing for quick chronological reference. * Message Bubbles: \* Primary Entry: The top entry is highlighted in a solid blue bubble ("Align check!!!"), distinguishing it as a significant milestone or status change. * Subsequent Notes: Following entries appear in light blue bubbles, containing descriptive text such as "note added," "final edit try segment," or more detailed observations about daily events. * User Attribution: Each note is clearly labeled with the author’s name (Siddharth Pansuria), their system role (Admin), and the exact time of entry (e.g., 10/05/2023 12:29 PM). #### Interaction & Input (Bottom Section) At the base of the feed is the input area for adding new information: * Comment Box: A text field labeled "Add a comment..." allows staff to input new case notes or updates instantly. * Action Icon: A blue send arrow on the right side of the input box facilitates the immediate posting of the note to the client's permanent record.
### New Note The New Note interface on the [Fieldworker platform](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) is a streamlined, vertical form designed for quick data entry. It ensures that every note is correctly categorized and attached to the right participant record for compliance and auditing purposes. #### 1. Mandatory Data Fields To maintain a high standard of record-keeping, certain fields are marked with an asterisk (\*), indicating they must be completed before the note can be saved: * \**CUSTOMER :* A dropdown selector where the user chooses the specific participant the note concerns. This ensures the note is filed in the correct digital folder. * \**NOTE :* The main body of the entry. This is a large, multi-line text area labeled "Enter your note here" where the staff member records their observations, interactions, or session details. #### 2. Optional Contextual Fields The form provides additional fields to add layers of detail, helping managers and auditors understand the context of the entry: * PROJECT (OPTIONAL): Allows the note to be linked to a specific initiative or program (e.g., a "Health Routine Check" project). * TASK (OPTIONAL): Links the note to a specific scheduled event, such as a "Home Visit" or "Monthly Monitoring" session. * NOTE TITLE (OPTIONAL): A short text field for a "subject line" (e.g., "Follow-up on Physical Therapy"), making it easier to scan the [Case Note](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) history later.
#### 3. Navigation and Submission * Create Note Button: A prominent blue button at the bottom of the form that finalizes the entry and adds it to the client's permanent record. * Back Navigation: A blue back-arrow icon at the top left of the modal allows the user to exit the form and return to the previous screen without saving, preventing accidental partial entries. ### New Voice Note The New Voice Note interface on the [Fieldworker platform](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) provides a hands-free alternative for documentation, allowing staff to record audio observations directly into a client's record. This is particularly effective for field-based Support Coordinators who need to capture detailed information immediately after a visit. Based on the [Case Note](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) documentation, here is a detailed breakdown of the voice note capture process: #### 1. Contextual Categorization To ensure the recording is audit-ready and easy to retrieve, the interface requires several key data points: * \**CUSTOMER :* A mandatory dropdown menu to link the recording to the specific participant. * \**PROJECT :* A mandatory dropdown to associate the note with a particular program or initiative (e.g., a "Health Routine Check"). * \**TASK :* A mandatory dropdown that connects the voice note to a specific scheduled event, such as a "Home Visit" or "Monthly Monitoring" session. * NOTE TITLE (OPTIONAL): An optional text field used to provide a "subject line" for the recording, making the [Case Note](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) history easier to navigate.
#### 2. Audio Capture Interface The central module of the form is dedicated to the recording mechanics: * Microphone Icon: Serves as the visual indicator for audio input. * Recording Timer (0:00 s): Displays the exact duration of the recorded audio in real-time. * STOP Button: Allows the user to end the recording session. * PLAY Button: Enables the user to review the audio playback before finalizing the submission, ensuring clarity and accuracy. #### 3. Finalization and Navigation Once the audio is recorded and the categories are selected, the user has two primary paths: * Create Voice Note Button: A large blue button at the bottom that uploads the audio file and its associated data to the [Fieldworker](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) permanent record. * Back Navigation: A blue arrow at the top-left of the modal that allows the user to exit the interface without saving, preventing accidental or incomplete uploads. > Field Tip: Using the Note Title field to summarize a voice note is highly recommended. It allows supervisors to understand the urgency or nature of the entry during a [Supervisor Review](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) without having to listen to the entire audio file first. ### Recent Notes (Mobile App) The mobile interface for viewing notes on the [FieldWorker platform](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) is designed to give field staff a chronological and interactive history of all interactions for a specific participant. This screen, specifically showing the Notes/Comments for customer Claire Hamara, is organized as follows: #### 1. Header and Navigation * Back Navigation: A blue arrow (`<`) at the top left allows the user to return to the previous participant list or dashboard. * Tabbed Interface: The screen is divided into two primary views: * Customer Details: For static demographic and profile info. * Notes/Comments (Active): The current view, highlighted with a blue underline. * Page Title: A clear header displays "Recent 10 notes for Claire Hamara:", providing immediate context on whose records are being viewed.
#### 2. The Chronological Notes Feed The main body of the screen features a series of white cards, each representing a single entry. The feed is organized with the most recent notes at the top. Each card follows a standard hierarchy: * Primary Header: Usually the title of the note or the name of the participant (e.g., "Initial Contact," "Project for Claire Hamara"). * Contextual Sub-headers/Tags: Displays the type of note or visit, such as "Unusual Incident" or "Habilitation Visit." * Metadata (Timestamp & Author): Every note includes a date and time stamp along with the name and role of the creator (e.g., "11/07/2023 11:32 AM by Maxx Walker (Admin)"). This is critical for maintaining a compliant audit trail. #### 3. Note Content and Types The content area of the cards adapts based on the type of information logged: * Text Notes: Displays a preview of the written [Case Note](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note), such as "Testing signature and check-in/out from the mobile app." * Voice Notes: Identified by a Speaker Icon (🔊) or an Audio Progress Bar (as seen in the "Sample task" card). This allows users to listen to recordings directly from the feed. #### 4. Row-Level Management Icons In the top-right corner of almost every card (except those that may be locked for audit reasons), there are two administrative icons: * Trash Can Icon: For deleting a note. * Pencil Icon: For editing the contents or details of an existing note. #### 5. Interaction Design The screen uses a vertical scroll layout, optimized for one-handed use in the field. The use of clear card borders and contrasting text ensures that Support Coordinators can quickly scan the history to find specific information, like a recent "Unusual Incident" or the details of the "Initial Contact." ### Recent Notes (Web App) The Notes tab on the [Fieldworker web app](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) serves as the centralized repository for all documentation related to a specific customer. It provides a clean, chronological feed of clinical and administrative observations that are essential for audit readiness and internal communication. Based on the [Case Note](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note) documentation, here is a detailed description of the layout and functionality of the Recent Notes section: #### 1. The Notes Feed Layout The interface is organized into distinct "Note Cards" listed in reverse chronological order. Each card contains specific metadata to ensure a clear audit trail: * Note Title: A subject line (e.g., "Medication history" or "Service on 12/26") that allows for quick scanning of the history. * Customer & ID: Confirms the record belongs to the correct individual (e.g., Franny Ramoz - 787810). * Creation Metadata: Lists the date and time of the original entry and the staff member responsible (e.g., Tracy Harris, Manager). * Update Metadata: Displays the last time the note was modified, ensuring transparency regarding any edits made after the initial submission. * Body Content: The narrative text of the [Case Not](https://app.gitbook.com/o/l66ooAirOIZbkkTyDA8V/s/FKFmA5xK4sMCcp1WP4Kc/fundamentals/concepts/case-note)e, provides the detailed facts and assessments of the session.
#### 2. Functional Management Tools At the top of the Notes section, several tools allow administrators and coordinators to manage large volumes of information efficiently: * Search Bar: Allows users to find specific keywords within the note history. * \+ Add Note: A blue button to immediately trigger the New Note modal for a fresh entry. * Filters & Sort By: Options to reorganize the feed based on date, author, or specific note types (e.g., unusual incidents vs. routine monitoring). * Edit Icon (Pencil): Located in the top right corner of each note card, allowing authorized users to update the content of an existing entry. ### 3. Sidebar Context While viewing the notes, the left-hand sidebar provides immediate access to the broader "Customer" context: * Customer Categories: You can quickly toggle between Active, Inactive, Prospects, and Dormant clients to locate the correct note feed. * Navigation Tabs: Persistent access to related modules like OVERVIEW, PROJECTS, TASKS, and FILES, allowing you to cross-reference notes with specific tasks or uploaded documents. This web interface is designed to mirror the mobile experience while providing a more expansive view for deep clinical reviews and supervisor audits.