5 Tips for Writing Better Therapy Notes

1. Use professional language as well as correct capitalization and punctuation.
2. Address the situation with relevant details.
3. Base notes on FACT (Observations are facts).
4. Avoid bias by leaving out opinions and assumptions.
5. Spell out acronyms before using them.
6. Say what you mean directly.

Good case notes are accurate. They are an accurate representation of what happened, rather than what you think happened. This is an important distinction.

A case note involves a social worker writing what they have done, what they have seen, their professional views, analysis of the situation and action plans. As a result, writing, clear, concise and factual case notes is an essential skill for social workers to nurture.

1. A Case Study Template.
2. A brief summary of the case.
3. An analysis and report on the services and interventions involved in the case.
4. Law and policy relevant to the case.
5. Critical analysis of applied social work values, theories and approaches.
6. Consideration of safeguarding, risk, needs, strengths.

Best practices for case notes Provide accurate details of the situation and what occurred (who, what, where, when, why, and how). Include discussions related to goals, action steps, timelines, strengths and barriers. Exclude sensitive information such as medical diagnoses and detailed information about family violence.

Progress notes are used to record the progress of treatment and are the substance of a client’s case record. These notes include assessment, diagnosis, and treatment interventions, referrals to community resources, preventive services, and coordination of care with other health care providers.

1. Be Clear & Concise. Therapy notes should be straight to the point but contain enough information to give others a clear picture of what transpired.
2. Remain Professional.
3. Write for Everyone.
4. Use SOAP.
5. Focus on Progress & Adjust as Necessary.

A ‘case note’ is the term applied to a chronological record of interactions, observations and actions relating to a particular client.

The note must include your client’s name, date of birth, and medical record number. After writing your note, reread the note to ensure what you have written is accurate. You should also sign and date your case management note. Unfinished or incomplete notes are not acceptable.

Writing a Case Study Analysis

1. Read and Examine the Case Thoroughly. Take notes, highlight relevant facts, underline key problems.
2. Focus Your Analysis. Identify two to five key problems.
3. Uncover Possible Solutions/Changes Needed.
4. Select the Best Solution.

Prospective case study methods are those in which an individual or group of people is observed in order to determine outcomes. For example, a group of individuals might be watched over an extended period of time to observe the progression of a particular disease.

Most case notes contain the same general information, which includes:

• the personal details of the client (these are on a referral sheet/cover sheet)
• family history.
• type of contact (whether you phoned the client or saw them at home, at a centre or in a formal counselling situation?)
• details of major issues.

Case management programs typically complete daily progress notes while residential and day support programs might complete a note after each shift or write a weekly summary note. Progress notes are important because they provide a report of the client’s previous and current services while in the program.

A case note provides a brief analysis of a case, identifying and examining the key elements of the decision, as well as placing the case in its wider legal and social context. Writing a case note.

Examples of fields a social worker may be employed in are poverty relief, life skills education, community development, rural development, forensics and corrections, legislation, industrial relations, project management, child protection, elder protection, women’s rights, human rights, systems optimization, finance,…