Case notes come in numerous shapes and sizes. Some agencies and schools might refer to them as case notes, progress notes, client documentation or clinical notes. Whether we like it or not, case notes are here to stay as an integral part of our professional lives. The growing demand for Career Development Facilitators (CDF) in both community agencies and schools is creating the need for these CDF's to appropriately document their interactions with clients/students. The ability to write not only a case note, but an appropriate, professional case note, is critical in our field. There are many different ways to write a case note and your agency/school will probably have a particular format they prefer you use. The critical part is to include all of the pertinent information about the client and your work together in order to create an effective file which can be used by your colleagues, yourself, and as a permanent record of the session. The steps below serve as a guideline to help you navigate the world of writing effective case notes.
Be concise yet thorough. Do not overwrite or "kitchen sink the note"
A tendency among beginning professionals is to include everything that was discussed in the session. While important concepts should not be omitted, the best notes contain enough information to generally describe the session, mention the client's progress toward their goals, and outline any assignments or next steps due. Case notes should be very concise and all unnecessary words should be omitted. Choose your words carefully and arrange your sentences for clarity. You want the note to be concise enough to enable a colleague to adequately serve the client in your absence, but not so long that they spend the first ten minutes of the session reading one note. A few excellent resources are The Elements of Style by Strunk and White (2000) and On Writing Well by Zinser (1998).
Simplify and retain factual information i.e. Do not throw the facts out with the bathwater
Use concrete, specific and descriptive vocabulary that conveys the essentials of the session. Try to refrain from jargon that may be misunderstood by colleagues or by the client. If using abbreviations, be sure they are approved by your agency or school. Strunk and White (2000) encourage writers to "Prefer the specific to the general, the definite to the vague, the concrete to the abstract" (p.15).
Write about what actually happened
CDF's may find themselves including their own assumptions and opinions about the conversation. It is always best to explore these impressions and issues directly with the client. Try to refrain from letting your opinions, prejudice or judgment of client motivation enter into your writing of the case note. Simply state what progressed and what was discussed in a factual manner.
Plan for the case note to be a part of their Permanent Record
As stated above, case notes are the official documentation of the session between professional and client. In many agencies and schools, case notes are to be kept in a client's file long after they have stopped coming for assistance/treatment. In some cases, these notes must be held (and could be subpoenaed) for up to 20 years. A familiar statement I learned early on in my career is to "write a case note as if it was going to be read by a judge." Ethical and confidentiality issues are equally important in writing case notes. Most states have specific guidelines about case note confidentiality, and the national Health Insurance Portability and Accountability Act (HIPAA) provides an even broader definition of case note confidentiality. Please check with your agency or school to learn the policies and procedures for handling and storing case notes.
What words can you use?
Below are some useful words used to describe actions taken in the session, including some that should be avoided in case notes.
Key words to use:
Words to Avoid:
How to format the note
Most agencies and schools will have a case note format/template already in place. As the growth of CDF's continue into new areas, some programs or settings may not have established guidelines for your notes. An effective note should contain three parts: the Goal, Intervention and Outcome. The Goal pertains to what the client has established as their needs/desires in working with a Career Development Facilitator. The Intervention section describes what techniques and materials were used in the session. This is where your professional CDF training becomes very useful so that you can professionally articulate the assessments, tools, or interventions. The final section describes the Outcome of the session and any homework assigned to the client.
Make sure your notes are current
As the demand for CDF's continue, it is likely that the demand on your time will continue to grow as well. Therefore it is extremely important to schedule in time to write case notes each day. Memories concerning sessions have a way of fading quickly, so be sure to write case notes as promptly as possible, and always document outside homework that you assigned to ensure that it will be reviewed next session. You will thank yourself at the beginning of each session when you are able to read (and remember) the main issues for each client. Your clients will also thank you for remembering them and for keeping your work together on track!
And lastly, don't forget to practice your writing! You are not alone if writing does not always come easily for you, but the more you practice the art of writing effective case notes, the easier it will become over time.
References
Strunk, W., Jr., & White, E. B. (2000). The elements of style (4th ed.). Boston: Allyn & Bacon.
Zinsser, W. (1998). On writing well: The classic guide to writing non-fiction. New York: Harper.
David A. Scott, Ph.D., LPC, NCC, CDFI is currently the Community Counseling Program Coordinator and faculty member at ClemsonUniversity. His areas of interest include career and community counseling, identity development, and at-risk youth. 205 Tillman Hall, ClemsonUniversity, Clemson, SC29634-0707. He can be reached at dscott2@clemson.edu
Michelle G. Scott, LISW-CP is currently in private practice in Anderson, SC.Her areas of interest include individual and couple's counseling. She can be reached at mgrantscott@yahoo.com