Lesson 16: Documentation

Attention

Learning Outcomes

Upon completion of this lesson's material, students will be able to:

  • Demonstrate how to document client interactions

Teaching

Read Chapter 24

It is important to accurately document all contact with clients and service providers when collaborating on a case. All documentation becomes a legal document which means it can be used in court or for any other legal purposes. It is important to know how to document your interactions appropriately.

It can be said..."if you did not document it, it did not happen"

Who is invested in being able to access documentation?

  • The client
  • Yourself
  • Your supervisor
  • Clinicial Supervisor
  • Insurance
  • Licensing
  • Legal Services

SOAL Notes

  • Subjective
  • Objective
  • Assessment
  • Plan

Learning to Write Case Notes using the SOAP Format

Tips on Writing Social Work Notes

Assessment

Lesson 16 Discussion

Select one of the dialogs presented in our textbook on pages 378-383 (either Mrs. Pell or Mr. Dudley). Answer the following questions succinctly (aim for no more than 6 sentences):

  1. The focus of the interview
  2. Your assessment based on a concise summary of behavior, appearance and affect.
  3. Any resolution that takes place.
  4. The reason for the next contact of the follow up that will occur.

Reflect on this process. What challenges did you find in this process? How did you pick out the most important details of the exchange to record in the client file? What additional challenges would occur in a real world exchange?

Lesson 16 Quiz

Review the following Case Studies and Contact notes. Identify what is wrong and / or left out of each Contact note. Rewrite an improved Contact note addressing these concerns.

Case 1

Jim come into the office today looking depressed. He said he wants another job. He sat slumped over in a chair and was unkempt. The worker wrote:

1/17/11 (Office Visit): Jim came into the office today to see about getting a different job. He is not working at present. Will call Goodwill to see if they can place him temporarily at the bakery where he was before.

Case 2

Alice has been asking to be relocated to another group home since December when another client, Cheryl, moved in. Alize and Cheryl have fought ever since. The staff is not sure which client should move, and they have communicated their concerns to the case manager. The worker wrote:

3/8/11 (Phone): Alice is carrying on again about her housemates. She is trying to get a better housing assignment. Will call the house where she is staying and see if something can be done.

Case 3

Kitsu is attending an intensive outpatient rehabilitation program for his drinking. He sees his case manager at the site about once every month. Recently it was decided that Kitsu is not making the progress he was expected to make. Part of this is due to his job, which he says is preventing him from coming to outpatient meetings regularly. To accommodate his night schedule at work, his services will now be given in the early evening before he goes into work. The worker wrote:

8/6/11 (Site Visit): Met with Kitsu and his therapist at the rehab program. Therapist is concerned about Kitsu's lack of attendance. Changes will be made in his program to facilitate attendance.