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) suggest case notes reflect the information provided in an interview and usually cover the following three broad areas:
Identifying, evaluating, and exploring the client's chief complaint and associated therapy goals.
Obtaining data related to the client's interpersonal style, interpersonal skills, and personal history.
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
Case notes cheat sheet
Date and time
Reason for contact or conversation
Appearance
Capacity to make decisions around the subject being discussed if applicable
Views of the person
Views of others
What did you see?
What did you do?
Any risks identified
Did you consult or share information with anyone? If so, why?
Your professional opinion and analysis
Action plan
Several different formats exist for writing case notes.
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.
