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.
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.