Writing case notes
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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

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Writing case notes

Writing Case Notes

A Collaborative Workshop presented by Child Development and Family Services and the Purdue Writing Lab


Good case notes

Good Case Notes

  • represent the client’s situation

  • provide a record of client care

  • enable an action to be taken based on their review

  • can be used in court, in school, by social agencies, and by insurance companies


Documentation is critical

Documentation is Critical

  • to clients and family members

  • to health care professional

  • to employers and managed care companies

  • to licensing and accreditation agencies


Types of case notes

DART

Description

Assessment

Response

Treatment plan

DAP

Description

Assessment

Plan

Types of Case Notes


Writing case notes

DART

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


Writing case notes

DAP

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


Descriptions

Descriptions

include objective information

when they report observable behavior seen by the therapist

include subjective information

when they report what the client says or feels


Planning and behavior goals

State behavior goals

in terms of:

Subject/Verb

Action/Object

Frequency

Duration

Mary will

give her son positive reinforcement

at least two times

every day for a week.

Planning and Behavior Goals


Behavior goals should be

Behavior goals should be

  • measurable

  • observable

  • of specific duration

  • achievable

  • relevant to the problem

  • appropriate and consistent with client values


Essentials of record keeping

Essentials of Record-Keeping

  • Be thorough yet concise.

  • Write clear, objective descriptions.

  • Write notes immediately after the session.

  • Proofread, but don’t erase information.

  • Consider how the client is portrayed.

  • Use respectful terminology and avoid jargon.


Be careful with wording

Be Careful with Wording

  • Respectful language

  • Nonjudgmental writing

  • Clear description

  • Key terminology


Respectful language

Respectful Language

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.


Nonjudgmental writing

Use

shows little motivation

resistant/determined

uses profanity

shows passive behavior

Instead of

lazy

stubborn

foul-mouthed

just sits there

Nonjudgmental Writing

Poor: He looks and smells like he hasn’t bathed in days.

Better: He has poor hygiene.


Clear description

Clear Description

  • Watch for misguiding, non-specific wording.

  • Show instead of tell.

    Poor: Chris was obviously nervous.

    Good: Chris was biting his nails and shifting in his seat.


Key terminology

Key Terminology

  • evidenced by

  • appears versus seems

  • client-active language

  • qualifying comments

    Poor: From her frown, Carol seems angry.

    Good: Carol appears angry, evidenced by her frown.


Maintaining records

Maintaining Records

  • Sign and date every entry.

  • Store the case notes securely.

  • Maintain confidentiality.


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