How do you document social work notes?

Know What to Write

  1. Write down information that will help jog your memory for the next session.
  2. Keep case notes objective.
  3. Leave out unnecessary details and filler.
  4. Note a client’s appearance or outfit only if it is relevant to their treatment.
  5. Be mindful of your own perceptions and biases.

What makes a good case note in social work?

Information recorded about a person or family should be impartial, accurate and complete with care taken to ensure that: Only details relevant to investigation, assessment, or the provision of a support or service are recorded. Case notes do not include derogatory or emotive language.

How do you document a case note?

  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.

What is social work documentation?

It is a communication tool with which social workers record their work; the means by which cases are managed; and the manner in which services are evaluated, assessed, and often reimbursed. It is a required professional social work function, a permanent record of client service provision.

How do you close a social work case?

Closing Cases

  1. Social work objectives / goals have been achieved and no further input is required.
  2. The family require ongoing support but there is no role for Social Care.
  3. Family decline further support and there is no statutory reason (e.g. child protection concern) for work to continue.

How do you write patient progress notes?

Progress Notes entries must be:

  1. Objective – Consider the facts, having in mind how it will affect the Care Plan of the client involved.
  2. Concise – Use fewer words to convey the message.
  3. Relevant – Get to the point quickly.
  4. Well written – Sentence structure, spelling, and legible handwriting is important.

How do you end a case note?

The conclusion should very briefly summarise the decision, the flaws and achievements that have been discussed throughout the case note, and your overall opinion.

What is a good case note?

Essentially, an effective case note is a combination of where you were, where you are, and where you will be going. This means that a good case note would paint the history and context of the client you are working with.

What are the documentation skills of social workers?

Documentation Skills Social workers document assessment information, crisis interventions and any correspondence with their clients or other professionals. Documentation must be thorough, accurate and timely in order to benefit both the client and the organization offering services.

What is the termination process in social work?

A client may terminate at any time for any reason. Ideally, termination occurs once the client and therapist agree that the treatment goals have been met or sufficient progress has been made and/or the client improves and no longer needs clinical services.