Here’s a situation that almost every social worker can relate to — they’ve sat in a meeting with a client and handled all the twists and turns that occurred, but then at the end of the meeting, when it’s time to write their casenote, they don’t know where to begin. Even during relatively brief client interactions, so much can happen that it can be difficult to break it down into a casenote. The lack of a national standard for casenotes adds to the challenge and sometimes before a worker organizes their thoughts about what to include, it’s time to head into the next meeting. Missing casenotes can start to pile up and before they know it, they’re on a common track for burnout.
Writing effective casenotes does not have to be difficult, however, learning to write effective casenotes is a skill and today I’m going to share with you tips that I’ve learned along the way.
What to Include in Effective Casenotes
✔️ Who?
It sounds simple, but when I was an entry-level social worker a common mistake that I made was getting too bogged down in the names and details during client meetings. Clients can share a lot of information about their family, neighbors, and even their pets; and initially I tried to include all that information in my casenote.Eventually, after struggling with lengthy casenote writing, I attended a training on documentation best practices. I learned that while it may be tempting to include every detail, effective casenotes should prioritize information relevant to the client and the current interaction.So, the next time that my client talked about their 76-year- old great aunt Dorothy, I knew which details to skip.
✔️ What
Another little-known documentation best practice that I picked up was to make sure that casenotes are framed in the lens of the services that were provided. It’s easy again to get lost in the details and to focus primarily on the client but neglect to include the worker’s interventions. Specifying the services that were provided however and the client’s progress are critical elements of a casenote, especially to funding-sources (Reporting Impact and Communicating to Grant Funders). Knowing the services provided also helps with supervision, quality control, and continuity of care.
✔️ The Date and Time
I know you’re thinking, of course the date and time should be included. It’s important to note however that unless workers are using time-stamped case management software, casenotes are often written retrospectively, making it challenging to track exact dates and times accurately. I know that I was not the only novice social worker running around with my meeting times scribbled on a sheet of notebook paper.
Tips to Keep in Mind
- Privacy & Confidentiality: Client interactions can include sensitive information and casenotes become an ongoing piece of a client’s record so workers should be mindful about the sensitive details that they include. If a client discusses a sexual dream for example, the details in most cases are probably best left off the record. Secure software, such as Casebook, supports compliance with privacy standards.
- Don’t Overuse Checkboxes: Beth Rontal, who is known as the “Documentation Wizard” in social work, notes that while checkboxes are a convenient tool, workers should never skip the narrative otherwise their casenote risks not having enough information.
- Get It Done: Ultimately the best documentation practices for you will be the ones that allow you to submit your casenotes in a timely manner. Find the system that works for you, don’t procrastinate, and forget perfectionism!
Let Case Management Software Help You
Case management software such as Casebook is a great tool that can help you produce effective casenotes. The templates available in Casebook help to organize your note and the customizable features can save you valuable time. Casebook also has the benefit of time and date stamps, including stamping any future corrections, and completing audits with software is a breeze.
Finally, Casebook stores casenotes in a secure system so that you’re safe to work on casenotes at your convenience while the notes also remain accessible to those who need them. Get a demo of Casebook today.
Don’t let writing casenotes be a cause of burnout (Social Worker Burnout Rate: Stats and Tips)! There are documentation practices and software, such as Casebook, that help workers to write more effective casenotes. Learning to write more effective casenotes also has the dual benefit of contributing to more effective meetings, which benefits clients and workers alike.
