As you are aware, many social workers have little time to write case notes. What would you
consider as “good enough” case notes?
Chey May
In the health care industry, people are very busy and might not have the time to
read through long case notes and sometimes, social workers write long stories.
My suggestion would be to make their case notes clear, concise, succinct and to
the point. Keying in the case notes into the system on time is also very important.
Jim Jim
I believe that as long as the main points that transpired in the session and followup required is captured in the case notes, it would be suffice. The case notes is
“good enough” when the reader is able to assess from the case notes the
progress of the case, the significant events, for example warnings given (for
probation) and the follow-up required on part of client and worker.
Iris
I would think that a good enough case notes covers these main categories
"objectives, content, assessment and plan of action"
Yoges
Case notes should have key headings as it would help to capture the essentials.
It’s the standard1 for most settings but it will vary a little on a couple headings for
some.
For new workers, it is important to start with a more extended case note
template to help frame thinking.
From your perspective, why are case notes important? And what are the risks and
consequences when case notes are not updated?
Jim Jim
Case notes are important documentation of the work done. It is necessary for the
next worker to take over and see clients due to case transfers or when they are
tasked to cover duty for those on leave. They might also be required to make a
decision in worker’s absence or in unexpected situations such as allegations
against worker, for example, for negligence. At times, the file could also be called
for during police investigations, like in the event of a client’s sudden death or
when client or accomplice denies involvement in an offence.
Lack of updated case notes will affect the confidence of the next worker in
continuing the work to be done and the confidence of the supervisor of the
quality of intervention done. It will also cause unnecessary stress to the worker
when information is required at critical points such as when a review is due or
1
Suggested standard key headings in case notes
1. Goals and objectives/ Focus of session
2. Follow up from last session (if not the first session)
3. Assessment
4. Intervention and service provided
5. Reflections and follow up needed
6. Next session date