๐Case 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) 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.
S.O.A.P. (Subjective, Objective, Assessment, Plan
D.A.P. (Data, Assessment, Plan)
B.I.R.P. (Behavior, Interventions, Response, Plan)
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