Social work progress notes, also referred to as case notes, are written records of clinical information and interactions with a client that are written in chronological order. These notes serve many purposes. They can remind us where we left off during our last meeting with a client and what to focus on in our next session. With client consent, these documents can be sent to other providers to increase the effectiveness of continuity of care. For those who accept insurance, their notes are essential to justifying reimbursement. Ample reason to spend time writing clear and effective notes.
Types of Social Work Progress Notes
While there may not be one master note that all social workers subscribe to, many providers find note templates to be useful tools to increase the ease and consistency of documentation. Different providers have different preferences on the format, and it comes down to what makes the most sense for you.
Several common templates include BIRP, Soap, and Dap. Each has a slightly different focus while also making sure that objective data, intervention, and follow-up are documented.
|Behavior: Issues/complaints the client demonstrated during the session including emotional and behavioral.|
Intervention: Intervention actions that were used to address the concerns.
Response: Client’s response to interventions. Did they assist in the alleviation of problem areas?
Plan: Follow up actions or treatment focus for future sessions.
|Subjective: Client’s description of issues or problem areas.|
Objective: Social worker’s observed quantifiable and measurable data.
Assessment: Evidence-based conclusions of observations.
Plan: Next steps to address issues.
|Data: Reason for the visit, client’s mental status, changes since the last session, and interventions used.|
Assessment: How the client responded to interventions, progress made, and any changes to treatment set goals.
Plan: Any additional steps the social worker or client is expected to take.
Essential Elements of Social Work Notes
Whether you decide to go with a popular social work notes template or create one of your own, there are certain pieces of information that should be gathered. A way to remind yourself of these elements is to ask yourself the following questions:
- Provider’s Name and Credentials
- Client’s Name and DOB
- Date of Service
- Length of Service
- Time of Day
- Location where service was provided (school, client’s home, office).
- Client complaints or issues that were the focus of the session.
- The interventions and skills you utilized to address issues.
- Connect how issues are addressed and interventions used to assist in overall set goals and objectives for the client.
- Next scheduled session date and time.
- Homework client is expected to complete before the next session.
- Referrals to other providers.
Best Practices for Social Work Notes
As mental health providers, we often find ourselves having to sift through a lot of information about what our clients are facing. We may be gathering information directly from our clients or from secondary sources, such as, family members, parole officers, or specialists. When we are dealing with others and even ourselves, it can be difficult to sort between objective facts and opinions.
As providers, our instinct, speculation, and curiosity can be helpful tools in sessions with clients. However, well-written case notes need to provide objective descriptions that are grounded in fact. One of the most important reasons for this is: respect for our clients. What we write is a medical record that can be used in legal proceedings, custody evaluations, and may be accessed by other healthcare professionals. Creating documentation that focuses on creating unbiased reports is one of the duties we have to our clients.
When I was starting in the mental health field, I had a supervisor that would remind me “chances are your client’s treatment will not end with you.” This was often in response to my groaning about the time spent documenting each encounter with a client. Over the years, my supervisor has been proven right again and again. For many clients we see, care may be an ongoing or a lifelong process. We need to use our documentation to ensure the next provider or auxiliary support is able to understand the issues that need to be addressed and the progress our clients have made.
With the high-demand nature of social work, it is not always possible to immediately do documentation after a meeting or session with a client. However, with each passing day remembering vital information gathered in a session can become more and more difficult. In order to make sure we have high-accuracy documentation, keeping up with paperwork is a must.
As social work notes are medical records, they are privileged and confidential documents. For those of us working with insurance companies, we are also bound by HIPAA (Health Insurance Portability and Accountability Act). Utilizing secure and HIPAA-compliant electronic health care documentation is a way we not only safeguard our client’s privileged information but also protect ourselves from legal action.