The more skilled you are at writing case notes… Writing is a key part of the job; social workers frequently write documents such as assessment reports, case notes, letters, emails, and support plans. They’re time-consuming and generally a drag. I have found your articles to be very helpful but are there any other suggestions or resources that could help improve my writing? The Purpose and Role of Clinical Documentation & Recordkeeping a. Make recommendations for further care and action. I hope that improving the plan section of your notes will help you to work more effectively with your clients. You need to include the 5 Ws: the who, what, when, where and why. Even if you are seeing the participant every I only endorse products I truly believe in. Writing case notes is a struggle for most social workers and therapists. and the Committee on Forensic Clinical Social Work New York State Society for Clinical Social Work, Inc. I have recently started a job in social services and I’m finding writing case notes according to the organization’s standards to be challenging. Photos courtesy of Canva.com. CONTENTS 1. So, don’t forget to document this important piece of your work. Yes. Social workers serve as a link between clients and community resources, providing vital human services that assist underserved populations. A framework and guidelines can take the stress out of documentation because it simplifies the process and provides a clear template to structure your thoughts and your notes. Australian Association of Social Workers Case notes are an integral and important part of practice for many Social Workers. Nobody likes writing psychotherapy or social work case notes! Obviously, your employment setting and training will lead you to your own unique set of intervention skills. A young person should be told that case notes and other records will be kept about them and they should be able to access them on request. In my personal productivity, paper is the best when taking notes in an administrative meeting or clinical setting. When well written, case notes provide accurate, objective descriptions grounded in fact and evidence. Case notes are a struggle for almost every social worker and clinician. Practical Suggestions for Preparing Social Work Records. I was hoping to find good examples of case notes. Creating individualized SOAP notes for group therapy can be somewhat time-consuming, but is essential for monitoring progress over time. If you continue to use this site we will assume that you are happy with it. Suicidal Ideation: 4 Documentation Tips. Purposes of Clinical Documentation c. The Role of Clinical Documentation in Quality Assurance 2. Documentation of … As a social worker, and you know what information needs to be provided in your note. Your email address will not be published. Case Notes Case notes are an integral and important part of practice for many Social Workers. Case Note Sample Narratives An assessor’s case notes have the ability to “tell the story” of a consumer’s medical and social situation in a manner which significantly augments information contained solely from completion of current assessment tools as well as the UAS-NY when implemented. Write On! It is not intended to nor should it be used as supervision or clinical guidance, or to diagnose or treat any mental health or medical issues. However, learning how to write good social work case notes will protect both you, your employer, and your client. We use cookies to ensure that we give you the best experience on our website. A. Required fields are marked *. I only endorse products I truly believe in. Rebeca Renata has been writing since 2005 and has been published on various websites. #dysfunctionalfamily #cod, #selfcare #selfcompassion #codependencyrecovery, #itsokaytonotbeokay #selfcare #validateyourself, #codependency #codependentnomore #codependencyreco, #selflove #selfcompassion #youmatter #loveyourself, #codependentnomore #codependencyrecovery #change. This edition of How to Write Better Case Notes focuses on the plan. My current note format has checkboxes for the interventions I used in session. Writing a process recording allows you to pay attention and to reflect on and analyze your own work B. Preparing to write your journal Review and reflect on the values, principles and ethics required for the practice of social work, and in particular, clinical social work practice. Properly documenting this will help you stay on track with your treatment goals and the client’s progress. Avoid making judgments or using labels to describe the client. Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Telehealth & Coping with COVID-19: Resources for Therapists, Guest Post: 5 Invitations for the Aging Services Professional, Guest Post: Fair Wages for Social Workers, How to Give a Social Work Clinical Case Presentation. Please leave a comment and let us know what other struggles you have with case notes or documentation. Sharon has worked extensively in Bay Area non-profits and successfully runs a private counseling practice in San Jose. LCSWA Clinical Case Summary Outline [Type or Print CLEARLY. It is not intended to nor should it be used as supervision or clinical guidance, or to diagnose or treat any mental health or medical issues. Writing Guide for Social Workers. (Under California law, the identical standard is applicable to Marriage and Family Therapists, Clinical Social Workers, and Professional Clinical Counselors. She is a California Licensed Clinical Social Worker with over 20 years in the field. The writer will contact the client by phone tomorrow, 4/21/15, at 10 am to monitor and re-assess the client’s suicidal ideation. Your email address will not be published. Often, social workers do not like recording this process in case notes. Each individualized group therapy note should also include the group type, the agenda for that session, the group members present, and the interventions facilitated by the group leader. I find that writing from oldest to newest (chronologically) is … You were hired for your particular skill set — your ability to provide services to clients through the interventions you use. Can you send me a copy of your note format? Overview. This page may contain affiliate links which means I receive a small commission on items purchased. Social Work documentation need not be painful and if you keep these tips in mind they can provide a framework for your documentation. The what needs to include information about any dimension of the patient’s experience that has been of focus prior to this visit, or a change that’s been indicated during this visit. Sharon Martin has a passion for clinical supervision, mentoring new social workers, blogging, and reading all things social work related. Read the Practicum Evaluation Booklet, examine and assess your own core competencies and use the lists given to guide you on the areas to be assessed in your journal. Interventions may seem second nature even to new social workers and, therefore, you may not even be aware of the interventions you are using. I hope that becoming aware of your interventions will help you to write better social work case notes. A little Saturday humor! Blog Like a Pro: Blogging Class for Therapists. Telehealth & Coping with COVID-19: Resources for Therapists, Guest Post: 5 Invitations for the Aging Services Professional, Guest Post: Fair Wages for Social Workers, How to Give a Social Work Clinical Case Presentation. She is a California Licensed Clinical Social Worker with over 20 years in the field. Sharon writes regularly for PsychCentral and the Good Men Project. I often see clinicians write a narrative of their sessions (more on this in a future post) leaving out the interventions! Medical social workers are health professionals who work in hospitals, outpatient medical clinics, substance abuse treatment facilities and other health-care organizations. Sometimes the plan is left out altogether. 8 Tips to Complete Your Social Work Documentation, More Great Articles and Tips Delivered to your Inbox, ©2015 Sharon Martin, LCSW ... (2002), “Learning to Write Case Notes Using the SOAP Format,” Journal of Counseling & … Often the plan is just the date of the next session. They enjoy meeting new clients, helping folks master problems, and watching clients and colleagues grow toward their full potential. Your case notes should be thorough enough that a coworker could step in for you in an emergency and know-how and what you are planning to work on in the next session. We use cookies to ensure that we give you the best experience on our website. × There used to be a time when clinicians did not regularly keep clinical notes. Do u recommend placing “interventions” in a seperate category? She's also the author of The CBT Workbook for Perfectionism. The case narrative is required during each six-month reporting period, but no longer to be submitted to the Board, except upon request. She's also the author of The CBT Workbook for Perfectionism. A common problem with writing case notes is that the plan seems to be an afterthought. Additional case studies provide examples of how to use the STEPs to format notes. I think it’s helpful to group them together. What to Write When a Client Tells You They Are Contemplating Suicide. This is an old fashion method, but the “tic-tic-tic-tic” lets you know that your time … This was very helpful, thank you. The Legal Mandate for Clinical Documentation in New York State b. Interventions aren’t necessarily complicated (they can be, but don’t overlook the simple ones). They’re time-consuming and generally a drag to write. They are records of interactions with the children, families, and persons relevant to a given case or incident. The clinical social work role at HSS remains true to this spirit. Case notes are a struggle for most social workers and therapists. Clinical social workers are exempt from releasing psychotherapy notes without patient authorization, and psychotherapy notes also are excluded from the provision that gives clients the right to see and copy their health information. She holds a Bachelor of Arts in psychology from the University of Connecticut as well as a Master of Social Work from the Smith College School for Social Work. They’re time-consuming and generally a drag to write. The more skilled you are at writing case notes, the faster they will go. Good case notes employ strategic, insightful inquiry and an understanding of larger case processes. Reviewing process recordings with your field instructor allows you to identify learning patterns, access your field instructor's factual and clinical knowledge and experience, recognize results of interventions V. The plan is to meet with the client next on 4/27/15. Your email address will not be published. Studies show that handwriting notes can be more effective than typing your notes. Sharon writes regularly for PsychCentral and the Good Men Project. Egg Timer Method. Getting the Most out of Clinical Supervision, Blog Like a Pro: Blogging Class for Therapists. Required fields are marked *. To write social work case notes, create an outline that covers each area of concern for the person in question. Fill in each section, and include an overview assessment of the situation. Plan: The client will utilize resources and strategies in her safety plan. The plan not only documents the date of the next session but planned interventions or issues to be addressed. They’re time-consuming and generally a drag to write. Social workers are people-oriented. Are they needed? Case notes are records of information and form a foundation for other core documents. For example, we are so used to providing empathy and active listening that we forget they are interventions. Case notes are a struggle for almost every social worker and clinician. The writer will contact the client’s psychiatrist to coordinate care. A social work assessment is a report written by a social worker evaluating a client’s educational, mental health, substance abuse, or occupational needs. This information was very helpful and has allowed me to complete my documentation of my sessions a bit faster. 2007). by Katherine Dunlap, Ph.D., MSW. The therapist does. Sharon Martin has a passion for clinical supervision, mentoring new social workers, blogging, and reading all things social work related. Your email address will not be published. You will need to interview the client and other significant parties knowledgeable about the client's background and current needs. This site is for informational purposes only. Sharon has worked extensively in Bay Area non-profits and successfully runs a private counseling practice in San Jose. Are they required? They’re time-consuming and generally a drag. Any changes to the current focus of treatment. This was very helpful! Photos courtesy of Canva.com. The client will complete a daily mood log and bring it to the next session. This covers both the social worker's personal observations of the client and any objective information from outside sources such as medical reports or the results of psychiatric testing. Please leave a comment and let us know what interventions you are using and any other challenges you have writing social work case notes. Whether you are a licensed clinical social worker or an MSW social worker, if you have a case load, chances are you need to write case notes: also referred to as progress notes. When a client expresses suicidal ideation i.e., a client tells you they no longer want to live and is able to describe how they would end their life, most counselors go into a … Progress Notes Progress notes are used to record the progress of treatment and are the substance of a client’s This page may contain affiliate links which means I receive a small commission on items purchased. Issues to be discussed at the next session. Writing Effective Case Notes Department of Human Services 8/12/09 Case Note Guidance . She specializes in writing about clinical social work and social services. Write the objective portion of the notes to include all factual information. Over the years, social work has evolved into a profession that has responded to social and economic changes and sought to address the needs of the population with the ultimate goal of improving their well-being. But who needs them? I use my Moleskine to make notes, draw out concepts, mind map, or … This edition of how to write better case notes focuses on interventions. If you continue to use this site we will assume that you are happy with it. The primary role of a social worker is to work with and support families/whānau to protect and care for their tamariki (children and young people). Writing case notes is a struggle for most social workers and therapists. The writer and client will meet for a session on 4/22/15 at 10 am to monitor and re-assess the client’s depression and suicidal ideation and continue to work on the goal of the client using safe coping strategies. Research has shown that record- keeping practices have an impact on client outcomes such that poor case notes can result in poor decision-making and adverse client outcomes (see …