Writing Case Notes. A Collaborative Workshop presented by Child Development and Family Services and the Purdue Writing Lab. Good Case Notes. represent the client’s situation provide a record of client care enable an action to be taken based on their review
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Writing Case Notes
A Collaborative Workshop presented by Child Development and Family Services and the Purdue Writing Lab
Description of the problem and your observations
Assessment of what may be going on
Response, or record, of what you did or suggested
Treatment plan, including goal setting
Description of the content and the process of the session
Assessment of what is going on
Plan for what will be done in the next session and in the meantime
include objective information
when they report observable behavior seen by the therapist
include subjective information
when they report what the client says or feels
State behavior goals
in terms of:
give her son positive reinforcement
at least two times
every day for a week.
For information such as race, gender, age, sexuality, and physical condition
Poor: Pat is a 26-year-old handicapped woman.
Good: Pat is a 26-year-old woman with a disability.
shows little motivation
shows passive behavior
just sits there
Poor: He looks and smells like he hasn’t bathed in days.
Better: He has poor hygiene.
Poor: Chris was obviously nervous.
Good: Chris was biting his nails and shifting in his seat.
Poor: From her frown, Carol seems angry.
Good: Carol appears angry, evidenced by her frown.