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As a case manager for a nonprofit, you understand that social work case notes are crucial to maintaining integrity in client services. Case notes can help you focus on your clients’ specific treatment goals and action plans while documenting their progress over time.
However, manually documenting case notes without structure or a template can be time-consuming and often lead to missing or incorrectly entering important client information.
In this article, we’ll provide you with two social work case note templates, the best practices for writing case notes, and what technological advances are available to streamline note-taking.
What are Case Notes in Social Work?
Case notes in social work document anything of note regarding a client’s case. Social workers must keep detailed, accurate records of the services provided and observations of a client and their situations.
Details logged in case notes can also help protect the social worker if they need to appear in court. Case notes provide a documented record of care that can be used in legal cases or during a client or social work organization audit.
With advances in social work practices and technology, social workers are encouraged to capture and enter notes digitally with case management software. Most digitally recorded social work case notes are created, stored, and shared through regulated and secure cloud-based servers like CaseWorthy’s to ensure client privacy.
Best Practices for Writing Social Work Case Notes
Effective social work case notes can improve treatment outcomes, lead to more efficient client service, and ultimately aid in clients accomplishing a goal. Here are six tips for writing social work case notes:
Make time for case notes
Incorporate case note-taking into your daily schedule so you can enter case notes on the same day. Some social workers schedule 10 minutes after each session to complete notes while the information is still fresh. Recording case notes while speaking with a client is also good practice so long as the client feels comfortable with you doing so in front of them.
Maintain objectivity
Social workers must be mindful of their biases and avoid dismissive or judgemental comments. For example, stating that the “client seemed sad and depressed” is not objective. However, “the client expressed that they have been unable to sleep, feel empty inside, and had a PHQ-9 score of 22 indicating severe depression,” is more objective and provides additional details about the symptoms they are experiencing.
Stay to the point
Case notes need to be detailed, accurate, and concise. So stick to the core facts and any information that will help you remember a discussion during a specific session, but leave out all unnecessary details.
Social workers must consider their client’s privacy when taking notes. A social worker may be legally obligated to hand over case notes if there is a court order or information request—meaning unnecessary details in a note may be used against the client.
Refer back to previous case notes
Before each session, take a few minutes to review previous notes to jog your memory about what you need to follow up on next. This review process makes sessions more efficient by knowing where you left off with a client last and what are the next steps.
Take notes in a way that works for you
Case management software like CaseWorthy can streamline the case note-taking process with templated forms and dashboards. These structured workflows make it easier for social workers to ensure they’ve addressed all necessary criteria in their notes without missing anything. CaseWorthy’s case management software also offers mobile and speech-to-text case note-taking, making it easier to capture observations quickly from anywhere.
Ensure your notes are secure
Social workers manage large amounts of sensitive and personal information about their clients. Case notes documenting a client’s medical information are also protected under the Health Insurance Portability and Accountability Act (HIPAA)—meaning they must be stored in a HIPAA-compliant manner.
CaseWorthy’s protected case management platform is HIPAA compliant with HMIS and LIHEAP functionality. All case notes are stored on private, proprietary cloud-based servers with 24/7 support.
Social Work Case Notes Templates
Social work case note templates vary based on the specific field of service and guidelines unique to an organization. Social workers will ask a client various questions based on their specific circumstances to establish an adequate, legally defensible record.
Since the main purpose of case notes is to provide documentation of individual encounters, social workers must often work within a template while using their best judgment to capture critical client information.
Here are two social work case note templates you can utilize with your clients:
Homeless Assistance Case Note Template
HMIS social worker professionals must capture specific information to provide the best possible care to their clients. Because individuals experiencing homelessness require a diverse set of possible needs, social workers must capture that information in a specific model to assist them.
As we said at the beginning of this article, structure and proven practices combine to make case note recording more effective and efficient. Below is a case note template example to document information during an initial visit with a client experiencing homelessness.
Homeless Assistance Intake and Case Note Template Example Entries:
Chief Complaint / Presenting Problems: Do they need temporary shelter, permanent housing, or transitional housing services? Are they experiencing financial or food insecurity? Do they have any physical or mental health concerns? Are they currently safe?
Clinical Observations: Is the client well-groomed? Are they behaving as though they are afraid? Remain entirely objective when summarizing the client’s appearance and behavior.
Referral Information: Which organization referred them to your office, and have any other referrals been made?
Demographics: What is their age, sex, and race? Are they married or single?
Want access to the full case note template?
Simply click the button below to get a fillable copy for yourself that you can start using today!
SOAP Case Note Template
Some social workers use the SOAP framework to organize their case notes. The SOAP process starts with documenting the client’s subjective thoughts and feelings. Then, the caseworker will notate their objective observations about the client’s circumstances. The social worker will provide an assessment of the goals and any challenges they will need to address first, as well as an action plan to meet those goals.
The SOAP framework can be conducive for unexpected encounters or encounters without clear guidelines to follow regarding documentation. Check out one of our social work case note templates with example information below to see the SOAP framework in action.
- Subjective: “I am feeling jittery, sad, and unable to work these days. I’m not sleeping and I was fired.”
- Objective: The client is a 26-year-old male and has a history of anxiety, depression, and panic attacks. PHQ-9 score was 22 for severe depression, and GAD-7 score was 14 for moderate anxiety.
- Assessment: The client’s mental health needs to be addressed through therapy first. Then employment can be secured.
- Plan: Client was referred to behavioral health for follow-up and will be seen by a licensed clinical social worker this week to begin an intensive short-term therapy plan. Client provided with groceries, food stamps, and 30-day bus pass. Client was referred to employment assistance.
Want access to the case note template?
Simply click the button below to get a fillable copy for yourself that you can start using today!
CaseWorthy’s flexible platform can adapt to countless case note configurations and case management workflows
CaseWorthy is built for social workers like you to serve your clients more efficiently and effectively. Our scalable and user-friendly platform features customizable reporting, dashboards, case note templates, mobile functionality, and case management workflows. If you like these templates provided above, we have good news–our team would love to help you build out your own case note templates within CaseWorthy.
Our case management platform experts can help your organization streamline case note-taking and administrative tasks. Schedule a walkthrough demo of our platform to see how CaseWorthy can benefit your organization.
