Definition, importance, information included, presentation, amending, legislation, terminating client, sharing with client, templates: SOAP, DAP, BIRP, BPSS, Intake report
Three sections follow:
1. Background Material that provides the context for the topic
2. A suggested Practice Approach
3. A list of Supporting Material / References
What are case notes?
Sommers-Flanagan (2009) suggest case notes reflect the information provided at an interview and usually cover the following three broad areas:
Identifying, evaluating, and exploring the client's chief complaint and associated therapy goals.
Obtaining data related to the client's interpersonal style, interpersonal skills, and personal history.
Evaluating the client's current life situation and functioning.
AASW (2016) add a fourth point: case notes should also include actions to be taken with regard to the client. Lillis (2017) elaborates: case notes could include reference to or inclusion of other documents, e.g. a care plan, a purchase order and a review summary. For Lillis, case notes are a combination of documents that successfully describe the situation, needs and actual services provided.
Why are case notes important?
Case notes have been emphasized as central to the work in which social workers engage. Case notes:
help focus work,
support effective partnerships with service users and carers,
provide a comprehensive, documented account of work with service users and their families,
assist continuity when workers change,
provide an essential tool for managers to monitor work,
can becomes a major source of evidence for investigations and enquiries.
Inadequate case records result in poor decision-making and adverse client outcomes (AASW, 2016; Lillis, 2017).
Healy and Mulholland (2007) expand many of the above points as follows. Case records are:
a vital information base for client work
formal and factual information—what the case consists of, what has been done to deal with it, when the case began, when the situation changed, the service modifications that took place, when the case ended and the final outcome
situational data on the client’s needs (phone calls, notes, emails, face-to-face interviews)
a way of clarifying the case situation for both the practice worker and the client
having the client speak, and the subsequent work presenting the case in a coherent and focused written form helps clarify the complex issues of the case for both worker and client
a means by which social workers and service users can make visible to others, such as team members, aspects of the social context of the client’s needs that might otherwise be ignored
recording case notes provides a focused social work coherence to them, frames the individuality of the client’s situation, and makes it easier for others dealing with the client to understand the situation
a method of promoting opportunities for collaborative responses in health and community services teams
a means of promoting the recognition of good practice
assist accountability, demonstrate efficiency and quality work as well as commitment and dedication
a vital information base for the achievement of consistency in social work intervention.
How and when should case notes be recorded?
Case notes can be recorded manually or electronically and should:
include on each page the name and DOB or other identifying information of the client
be recorded as soon as possible after an interaction or event
be typed or, if handwritten, clearly readable
include the name, signature and profession/role of the author
include the time of contact, particularly where there are a high volume of interactions in a day (AASW, 2016; Sommers-Flanagan, 2009).
What information should be included in a case note?
There are no prescribed rules for what we put in or out of case notes. It depends on the agency rules and our view. However they are legal documents that can be called for by the court. So in writing them consider
Who is going to read them?
How will / can the information be interpreted?
What needs to be there so someone else can go on with the case if you leave?
Put context around any judgements you make, do not just give your opinion (Maple, 2012).
Information recorded about a client should be impartial, accurate and complete with care taken to ensure that:
only details relevant to the provision of a support or service to which the client has consented are recorded
when working with involuntary clients this means recording information relevant to statutory practice
notes are free from derogatory or emotive language
subjective opinions are qualified with relevant background information, theory or research
relevant information is not omitted. (AASW, 2016)
It is important to listen for what is important to the client. Signs that a matter is important are:
Word, phrase or topic repetitions (e.g. “money” may be mentioned four times)
Use of colloquial phrases of emphasis (e.g. ‘after all I said last time’, ‘I mean’, ‘and then where will she be’)
Swearwords (e.g. ‘it’s bloody awful’)
Tone of voice, such as extra loudness or long pauses followed by a strongly expressed phrase (Healy & Mulholland, 2007)
The guiding principle for deciding what information should be included in a case note is whether it is relevant to the service or support being provided. The type of information that is considered relevant may include:
a range of biopsychosocial, environmental and systemic factors impacting on the client; this includes consideration of an individual's culture, religion and spirituality
risk and resilience factors
facts, theory or research underpinning an assessment
a record of all discussions and interactions with the client and persons/services involved in the provision of support including referral information, telephone and email correspondence
a record of non-attendance, either by the Social Worker or client, at scheduled and agreed meetings or activities
evidence that the Social Worker and client have discussed their respective legal and ethical responsibilities. This may include:
client rights, responsibilities and complaints processes
the parameters of the service and support being offered and agreed to
issues relating to informed consent, information sharing, confidentiality and privacy
efforts to promote and support client self-determination and autonomy
specific responsibilities to clients in particular settings such as private practice or rural settings as per the relevant Association’s Code of Ethics document
professional boundaries and how dual relationships may be managed
record keeping and freedom of information
relevant legislative requirements and their possible implications for practice
details of reasons and any related actions or outcomes leading up to or following the termination or interruption of a service or support (AASW, 2016). Professional views may often be missing in case notes because social workers position their own subjectivity as irrelevant, or as threatening the achievement of accuracy and comprehensiveness. However, at times it is important to express it, e.g. where it is needed to justify an action (Lillis, 2017).
Other writers provide their own details of what should be included in case notes. In particular Oranga Tamariki (2022a) (the New Zealand Ministry for Children) provides general points when writing case notes. TheraNest (2020) draws together three sources to present a detailed list. This information is included under each of the references in the Supporting Material/References section that concludes this topic.
How should information be presented?
There are a number of case-writing models available to social workers. Some of them provide general guidance for writing case notes while others are specific to a service type or context. In addition, many organisations have policies and procedures around case recording (AASW, 2016). Case note templates are discussed further in the Practice Approach section that follows.
Sommers-Flanagan (2009) suggests the following should be used to structure case notes:
Most reports begin with identifying the reason for referral.
They then examine specific behavioural observations made by the interviewer.
The client’s specific problem is stated in some detail, along with its unique evolution. The history and description of several problems may be included.
For some clients past treatments or history of counselling can be listed.
Relevant medical history should be included, e.g. general health, recent illnesses, chronic physical illnesses or hospitalizations, prescription medications.
Include a social and family history where relevant.
Current ability to manage activities around daily living (ADLs) should be mentioned where relevant. This section can be expanded to include a description of the client’s psychological functioning, cognitive functioning, emotional functioning, or personality functioning.
Include some discussion of diagnostic issues, even if they are broad (e.g. depression, anxiety, substance use, eating disorder). For some clients, more detail may be appropriate.
Include a paragraph around case formulation and treatment plan: how the worker views the case and how the worker is likely to proceed in working with the client.
Can case notes be amended or changed at a later date?
If a change must be made to correct an error or omission, the change can be recorded as a new and separate case note. It is advisable to provide an explanation for its earlier absence or inaccuracy. Add, if possible, a note in the margin of the original case note referring the reader to the additional or amended detail (AASW, 2016).
What are the legislative responsibilities with regard to case notes?
Case notes may be subject to, and can be subpoenaed, for a range of legislative processes and requirements. The nature of these requirements may differ between organisations, districts, States and countries. Therefore it is important for Social Workers to:
be familiar with the specific legal requirements and processes impacting on practice
consider the implications of Federal and State legislation to the recording of case notes
understand how these requirements are implemented within their organisation (where relevant)
understand what policies and procedures may need to be implemented when working in private practice (AASW, 2016).
What should happen with case notes on termination of a service or support?
Termination or interruption of services should be included in case notes. Given termination may be unanticipated (e.g. departure of a social worker), it is particularly important to ensure that case notes are maintained and updated as soon after an interaction or event as practicable (AASW, 2016).
Sharing case notes with the client
It is important that clients can view reports, but they may also misinterpret information in a report unless offered guidance. The following guidelines are suggested:
Inform clients at the outset that records will be kept, and clients can have access to them.
Inform clients that some portions of the records are written in language designed to communicate with other professionals; consequently, the records may not be especially easy to read or understand.
If clients request their records, tell them you would like to review the records with them before releasing them, so as to minimize the possibility that the records are misinterpreted.
When clients request records, schedule an appointment (free of charge) with them to review the records together.
If clients are no longer seeing you, are angry with you, or refuse to meet with you, you can (a) release the records to them without a meeting (and hope the records are not misinterpreted), or (b) agree to release the records only to another licensed professional (who will review them with the client).
Whatever the situation, always discuss the issue of releasing records with your supervisor, rather than acting impulsively on your client's request (Sommers-Flanagan, 2009).
One of the themes to emerge from the literature around case notes is how they are “setting dependent” (AASW, 2016); Maple, 2012; TheraNest, 2020). Prescribed rules for what is included or excluded varies from agency to agency. However a number of key points from the Background Material section above. They include the following:
Each page should have the client's name, client's date of birth, social worker’s name and date of the interaction.
Case notes should be written as soon as possible after the interaction.
Consider who is going to read notes and how this should impact on writing style.
Information about a client should be impartial, accurate, complete, and free from emotive language.
Subjective opinions should be qualified with relevant background information, theory or research.
Be clear and consistent – don’t include extra details that are not to the point.
Sign and date the case notes when completed
Relevant information recorded in case notes may include:
The reason for the referral; the client’s specific problems
Evidence that legal and ethical responsibilities of both worker and client have been discussed
Relevant behavioural observations
A range of biopsychosocial, environmental and systemic factors impacting on the client. When relevant:
social and family history
ability to manage activities of daily living
culture, religion and spirituality
Risk and resilience factors
An assessment supported by facts, theory and/or research
A plan of action based on this assessment
A Selection of Formats for Writing Case Notes
Several different formats exist for writing case notes. TheraNest (2020) highlights three:
S.O.A.P. (Subjective, Objective, Assessment, Plan
D.A.P. (Data, Assessment, Plan)
B.I.R.P. (Behavior, Interventions, Response, Plan)
SOAP (Subjective, Objective, Assessment, Plan)
These four sections try to ensure case notes are complete, yet concise.
Subjective: What the client says about the problem; opinion-based information from the client including their goals, concerns, feelings, perceptions of their own problems. Also include relevant information from other family members or close friends.
Objective: Information that is fact-based, verifiable and quantifiable. This can be direct observations of the client. This might include things like the client’s appearance, body language and other obvious behaviour.
Assessment: Using subjective and objective information to assess the situation; a conclusion or recommendation could be included, with evidence as to why conclusions have been drawn.
Plan: The plan of action, e.g. referrals to other agencies, goals, timeline targets, i.e. the steps to take to assist the client meet their needs (AGS, 2019; Government of Northwest Territories Canada, n.d.; Moore, 2022a).
AGS (2019) provides two examples of case notes to illustrate the above. The AGS website also provides a template social workers can use to record case notes.
Examples of SOAP case notes
what the client says
Client at the teen shelter stated: “My parents didn’t want me, so I left, now I can do what I want. What happens, happens.”
Elderly client living with family stated: “I don’t really know where I’m supposed to go. My family says my medical needs have become too much for them, and I don’t want to put anyone out.”
Objective: facts and observations
Parents have been calling to find their child. Teen is 15 and homeless and left home 2 months ago. PHQ-9 score was 14 for moderate depression.
Client is 85 years old and has chronic obstructive pulmonary disease. In-home medical care has become expensive. Family dynamics seemed stressed during my home visit.
Assessment: assess the situation + conclusion
The best case would be for family reunification, but the teen needs to have depression and negative thoughts addressed through therapy first.
The client’s health condition isn’t helped by a stressful dynamic at home. The additional medical needs have become too much for his daughter and son-in-law to manage. A nursing home would provide a better atmosphere for the client and would offer companionship.
Plan of Action: steps to take; referrals
Have the teen seen by a licensed clinical social worker this week to start a short-term therapy plan. Contact parents and recommend a mediated reunification so the teen doesn’t disappear again.
Provide counselling for family and client. Refer them to Shady Grove Nursing home and facilitate an initial visit. If all goes well, facilitate the move for the client to the nursing home.
DAP (Data, Assessment, Plan)
The Data heading covers everything that occurred during a counselling session, including but not limited to a client’s observable responses, affect, traits, and behavior. This section includes specific, objective information about the session’s focus, what was said, and more, in order to answer the question: “What did I observe?”
Under Assessment, social workers interpret and analyze the data in the previous session. This involves applying some professional subjectivity and may result in clinical hypotheses or findings. Here, social workers might record things like how a session related to a client’s overall treatment goals, a working hypothesis, and/or a probable diagnosis of a client’s condition.
The Plan section is used for making decisions and recommending a plan of treatment for the client. Here, the objective and subjective data from the previous two sections are used to inform a social worker’s strategy or next actions – often between the current session and the next. This could include recommendations for therapy or lifestyle changes, among other short- and long-term treatments (Moore, 2022b).
The key difference between SOAP and DAP formats is that the former breaks down the information about a session into two discrete sections, which can be highly useful in healthcare contexts where medications, blood results, and other clinical data can inform a patient’s treatment (Moore, 2022b).
BIRP (Behaviour, Interventions, Response, Plan)
Behavior (Presenting the Problem) This section records the subjective and objective details that were observed (CF SOAP outline above). This section can also contain details about the session itself, such as where it took place.
Example: Met with client X in the office. The most recent assessment shows they are presenting symptoms of anxiety. Today they showed signs of exhaustion, lack of focus, and looked tired. They reported not being able to sleep in the past week and feeling overwhelmed by work.
Interventions This section outlines the methods used to reach the goals and objectives of the therapy. It’s a concise summary of the conversation, focusing strongly on the therapist’s actions and the patient’s reactions.
Example: Through client-centered techniques, this writer encouraged the patient to expand their thoughts about their work. Negative thoughts were identified and challenged. The patient was asked to see if there is a link between their insomnia and the stressful period at work. The connection was successfully made and normalized through discussion. The conversation then focused on the specific work-related triggers that may have led to insomnia. A mild sleep aid was prescribed.
Response In this section, the therapist should record the client’s response to the intervention, including what the client said and how they reacted.
Example: The patient initially rejected the link between their insomnia and stress at work. When asked how work made them feel, the patient became silent, reduced eye contact, and disengaged from the conversation with the writer. After a few moments of thinking, the patient was able to describe their own feelings in relation to their work.
Plan The plan outlines when the next session will take place, and its focus.
Example: The next appointment scheduled for September 16, will assess the client’s response to the sleep aid and reassess their feelings about work.
Biopsychosocial-Spiritual Approach (BPSS)
The BPSS is used quite frequently by social workers, especially in their initial dealings with clients. The following is a template that could be adapted as necessary for different clients. Other templates for the BPSS can be found in a separate topic on this website at https://www.thesocialworkgraduate.com/post/bio-psychosocial-spiritual-assessment
Client contact details:
Medical / psychological history:
Employment / education:
Other issues: Should check areas in BPSS to see if any other topics should be included
Planned intervention and referrals:
Pacheco (2014) suggests social workers can develop a template that can be written over when taking notes.The template can contain prompts to ensure the social worker does not forget to touch on certain areas. An example using the BPSS approach is shown on the right.
This is quite simple to make: type up your page with the prompts, highlight the prompts, and choose a light colour from the available font colours, e.g.tan background 2.
Pacheco’s approach could be used with other approaches too, such as SOAP, DAP and BIRP.
A number of other writers suggest case notes templates, and these have been included under their reference in the following Supporting Material / References section.
Healy and Mulholland (2007) suggest three approaches: topic sentences, problems to be solved, and expressing client concerns.
Oranga Tamariki (2022b) provide an example of a good and poor case note
Social Work Haven (2021) has developed a case notes cheat sheet
Sommers-Flanagan (2009) provide a detailed intake report template.
AASW: Australian Association of Social Workers. (2016). Case notes. Retrieved from https://www.aasw.asn.au/document/item/2356
AGS: Airiodion Global Services. (2019). A simple (but detailed) guide on different types & stages of social work processes. Retrieved frpm https://www.airiodion.com/social-work-process/
Healy, K., & Mulholland, J. (2007). Writing Case Records. In K Healy & J Mulholland (Eds.), Writing Skills for Social Workers (pp. 68-86). Sage Publications.
Three Methods for Writing Case Notes
Topic sentences—provide the gist but leave out the detail
Problems to be solved
Expressing client concerns—state the client’s concerns as well as the social worker’s professional judgement
An example of each of the above follows based on this situation: The grandmother said: It was last Friday she came round, late as usual, and she hadn’t brought me any money to buy food for the kid after all I said last time it happened - no money and no food either - I mean I don’t mind looking after the kid - it’s bloody awful the way she treats that child - but on my pension I can’t pay for its food and that - I mean if she doesn’t give me some money soon I will have to stop caring for the kid and then where will she be?’
This case is about childcare by grandmother. Grandmother is client. The mother is in paid employment; she finds it difficult to supply money to the carer, and to pick up the child on time. The carer is unhappy about the money situation, and to lesser degree the time problem, and threatens to stop the caring.
Problems to be solved:
This case is about childcare by grandmother. Problem 1 - money, since mother is erratic about providing it.
Problem 2 - time of child collection, since mother is often late.
Problem 3 - carer is unhappy about the money situation, and to a lesser degree the time problem, and threatens to stop the caring.
[You may wish to go one step further and alert the attention of a specific team member by writing Problem 3 as: Problem 3 - ’In my view, the carer may need counselling’, or ’Carer and mother may need mediation’.]
Expressing client concerns:
Client, grandmother as carer, complained about child’s mother supplying no money and being late. She warned that she could not continue with the childcare unless she was paid.
Lillis, T. (2017). Imagined, prescribed and actual text trajectories: The ‘problem’ with case notes in contemporary social work. Text and Talk, 37(4), 485–508. http://dx.doi.org/doi:10.1515/text-2017-0013
Government of Northwest Territories Canada. (n.d.). SOAP case notes guide. Retrieved from https://www.hss.gov.nt.ca/professionals/sites/professionals/files/resources/soap-case-notes-guide.pdf
GoodTherapy. (2020). For social workers: Tips for writing case notes. Retrieved from https://www.goodtherapy.org/for-professionals/business-management/private-practices/article/for-social-workers-tips-for-writing-case-notes
Maple, M. (2012). Case notes. Lecture notes, HSSW 100, University of New England, Australia.
Miller, K. (2022). BIRP notes: A complete guide on the BIRP note-taking format. Retrieved from https://quenza.com/blog/birp-notes/
Moore, C. (2022a). Writing SOAP notes, step-by-step: Examples + templates. Retrieved from https://quenza.com/blog/soap-note/
Moore, C. (2022b). How to write DAP notes: 5 best templates and examples. Retrieved from https://quenza.com/blog/dap-notes/
Oranga Tamariki (New Zealand Ministry for Children). (2022a). Keeping accurate records – guidance. Retrieved from https://practice.orangatamariki.govt.nz/practice-approach/practice-standards/keep-accurate-records/keep-accurate-records-guidance/
Oranga Tamariki - New Zealand Ministry for Children (2022a) suggests the following general points in providing guidance for social workers when writing case records. Each point below is expanded in the actual document.
Implement the practice standards for each tamaiti (child) in case notes, assessments, plans and reports
Record the process of engaging with, assessing, making decisions and reasons for decisions
Ensure what is recorded is easily understood
Provide adequate support if tamariki (children) want access to records
Keep personal information safe and secure
Document any key decisions made, or actions taken, the rationale for decisions or actions and the next steps.
Records identify the key people with whom engagement has occurred
Document views on relevant people involved in the case and how this has informed decision-making
Develop a chronology of critical key events and changes for te tamaiti (the child) and whanau (family) across their lifespan
Document how tamaiti (child), their whanau (extended family), caregivers or others working with the have responded to social worker decisions
Choose an appropriate communicate approach when communicating with clients
Include in notes how the family responds to decisions made
Document any oversight/approval obtained for key decisions that require it
Record discussions, key points and decisions made during supervision or case consults, including next steps
Review records often to keep the current and accurate
Oranga Tamariki (New Zealand Ministry for Children). (2022b). Case note examples. Retrieved from https://practice.orangatamariki.govt.nz/previous-practice-centre/policy/recording/key-information/case note-examples/
Example of a good case note
Example of a poor case note
Header: Talking to John, Shirley
Venue: home address
John Last-name (DOB d/m/y)
Shirley Last-name (caregiver)
Graeme Last-name (caregiver) – not home, at work.
Name of social worker (Social Worker)
Purpose of visit
Ensuring John’s care placement is supported and meeting all his wellbeing needs.
John took me into his bedroom to show me all his toys and games. We played connect four and then cards. John talked about Jim (Paternal Grandfather) giving him the Sponge Bob cards for Christmas.
John had good eye contact and was able to speak freely, chatting and answering questions. His hand eye coordination was great; John showed me how he could make a helicopter which then fired bullets. John talked about Fluffy (cat) and Peaches (dog). John showed me that Peaches will sit down on her blanket when John says “sit”.
John talked about how much he loves rugby and can’t wait for the season to begin. John is hoping to have the same coach he had last year (called Wogs) because he really liked him. John said he likes playing touch at lunchtimes at school with his mates Daniel, Ethan, Dante, Jayden and Nikau. If there’s not a touch game on John usually plays basketball or tennis with his mates.
John says he is happy seeing his mum. John didn’t expand on this topic.
Shirley had made afternoon tea; we sat at the dining room table together. John stayed in his room playing with his Lego. Shirley said she was “very happy” with how things were going and that John was a “good boy”.
John is playing cricket on Saturday mornings between 10am until 12pm. Graeme takes him to this and watches the games.
John is going well at school however his teacher is a bit concerned about his lack of concentration at times. The teacher said to Shirley that John daydreams a lot and when the teacher asks him what he is thinking about, he says rugby.
John still sees Tracey (mum) every Friday afternoon between 3.30 and 4.30pm at our office. Maggie (resource worker) picks John up from school and takes him to access, then drops him off at Shirley’s afterwards. Tom (Tracey’s partner) sometimes comes along to the visits with Tracey. No issues raised by Shirley.
Finances for John’s rugby subs and a pair of boots;
Contact the school teacher to discuss John’s daydreaming, does this impact on his learning?
Call Shirley/ Graham by (date), to organise the next home visit.
Header: H/V to John
Met with John and Shirley. John took me into his bedroom to show me all his toys and games. We sat on the floor and played Connect Four and then had a game of snap with some Sponge Bob cards John had got for Christmas from Jim. John then showed me a lego set he had where you can make trucks, cars, motorbikes and even a helicopter. John showed me how he could make the helicopter which then fired bullets. John also showed me Shirley’s cat, Fluffy and Dog, Peaches that he likes. John showed me that Peaches will sit down on her blanket when John says “sit”.
Shirley had made afternoon tea, so we then sat at the huge dining room table and had scones with jam and cream and a cup of tea. Shirley said she was very happy with how things were going, and that John was a good boy. He is playing cricket on Saturday mornings at 10am and this goes until 12pm. Graeme takes him to this and watches the games. Shirley wanted to know if we could pay for John’s upcoming rugby subs and a pair of boots. Shirley wants to get John a good pair of Nike boots from Rebel Sport that will last the distance rather than cheap ones from the Warehouse that will fall apart halfway through the season.
Shirley also said that John is going well at school however his teacher is a bit concerned about his lack of concentration at times. The teacher at KVPS has said that John daydreams a lot and when the teacher asks him what he is thinking about, he says rugby. John really loves rugby and can’t wait for the season to begin. John wants to have the same coach he had last year; a guy called Wogs who John really liked. John said he likes playing touch at lunchtimes at school with his mates Daniel, Ethan, Dante, Jayden and Nikau. If there’s not a touch game on John usually plays basketball or tennis with his mates.
John still sees Tracey every Friday afternoon between 3.30 and 4.30pm at our office. Maggie picks John up from school and takes him to access, then drops him off at Shirley’s afterwards. Tom sometimes comes along to the visits with Tracey.
I thanked Shirley for the afternoon tea and told her I’d be back in a couple of months.
Pacheco, I. (2014). Note taking templates for clinical social work. Retrieved from http://socialworktech.com/2014/06/23/note-taking-templates-for-clinical-social-work/
Social Work Haven. (2021). Sample case notes from social work you can learn from. Retrieved from https://socialworkhaven.com/sample-case-notes-for-social-work/
Case notes cheat sheet
Date and time
Reason for contact or conversation
Capacity to make decisions around subject being discussed if applicable
Views of the person
Views of others
What did you see?
What did you do?
Any risks identified
Did you consult or share information with anyone? If so, why?
Your professional opinion and analysis
Somers-Flanagan, J., & Sommers-Flanagan, R. (2009). Intake interviewing and report writing. In J. Sommers-Flanagan & R. Sommers-Flanagan (Eds.). Clinical interviewing (4th ed., 175-212). John Wiley & Sons.
Sample Intake Report Outline
Use the following intake report outline as a guide for writing a thorough intake report. Keep in mind that this outline is lengthy and therefore, in practical clinical situations, you will need to select what to include and what to omit in your client reports.
NAME: DATE OF BIRTH: AGE: DATE OF INTAKE: INTAKE INTERVIEWER: DATE OF REPORT:
I. Identifying Information and Reason for Referral
A. Client name
D. Racial/Ethnic information
E. Marital status
F. Referral source (and telephone number, when possible)
G. Reason for referral '(why has the client been sent to you for a consultation/intake session?)
H. Presenting complaint (use a quote from me client to describe the complaint)
II. Behavioral Observations (and Mental Status Examination)
A. Appearance upon presentation (including comments about contact, body posture, and facial expression)
B. Quality and quantity of speech and responsivity to questioning
C. Client description of mood (use a quote in the report when appropriate)
D. Primary thought content (including presence or absence of suicidal ideation)
E. Level of cooperation with the interview
F. Estimate of adequacy of the data obtained
III. History of the Present Problem (or iIlness)
A. Include one paragraph describing the client's presenting problems and associated current stressors
B. Include one or two paragraphs outlining when the problem initially began and the course or development of symptoms
C. Repeat, as needed, paragraph-long descriptions of additional current problems identified during the intake interview (client problems are usually organized using diagnostic-DSM-groupings, however, suicide ideation, homicide ideation, relationship problems, etc., may be listed)
D. Follow, as appropriate, with relevant negative or rule-out statements (e.g., with a clinically depressed client, it is important to rule out mania: "The client denied any history ofmanic episodes.")
IV. Past Treatment (Psychiatric) History and Family Treatment (Psychiatric) History
A. Include a description of previous clinical problems or episodes not included in the previous section (e.g., if the client is presenting with a problem of clinical anxiety, but also has a history of treatment for an eating disorder, the eating disorder should be noted here)
B. Description of previous treatment received, including hospitalization, medications, psychotherapy or counselling, case management, and so on.
C. Include a description of all psychiatric and substance abuse disorders found in all blood relatives (i.e., at least parents, siblings, grandparents, and children, but also possibly aunts, uncles, and cousins)
D. Also include a list of any significant major medical disorders in blood relatives (e.g., cancer, diabetes, seizure disorders, thyroid disease)
V. Relevant Medical History
A. List and briefly describe past hospitalizations and major medical illnesses (e.g., asthma, mv positive, hypertension)
B. Include a description of the client's current health status (it's good to use a client quote or physician quote here)
C. Current medications and dosages
D. Primary care physician (and/or specialty physician) and telephone numbers
VI. Developmental History (This section is optional and is most appropriate for inclusion in child/adolescent cases.)
VII. Social and Family History
A. Early memories/experiences (including, when appropriate, descriptions of parents and possible abuse or childhood trauma)
B. Educational history
C. Employment history
D. Military history
E. Romantic relationship history
F. Sexual history
G. Aggression/Violence history
H. Alcohol/Drug history (if not previously covered as a primary problem area)
I. Legal history
J. Recreational history
K. Spiritual/Religious history
VIII. Current situation and Functioning
A. A description of typical daily activities
B. Self-perceived strengths and weaknesses
C. Ability to complete normal activities of daily living
IX. Diagnostic Impressions (This section should include a discussion of diagnostic issues or a listing of assigned diagnoses.)
A. Brief discussion of diagnostic issues
B. Multiaxial diagnosis from DSM
X. Case Formulation and Treatment Plan
A. Include a paragraph description of how you conceptualize the case. This description will provide a foundation for how you will work with this per- son. For example, a behaviorist will emphasize reinforcement contingencies that have influenced the client's development of symptoms and that will likely aid in alleviation of client symptoms. Alternatively, a psycho- analytically oriented interviewer will emphasize personality dynamics and historically significant and repeating relationship conflicts.
B. Include a paragraph description (or list) of recommended treatment approaches.
TheraNest. (2020). Elements of effective case notes for social work. Retrieved from https://theranest.com/blog/elements-of-effective-case-notes-for-social-work/
The guiding principle for writing effective case notes is to include content relevant to the service(s) or support provided. The specific content will vary based on your specific situation, but AASW broadly recommends the following:
The biopsychosocial, environmental and systemic factors impacting the client, including the client’s culture, religion/spirituality
Risk and resilience factors
Facts, theory or research underpinning an assessment
A record of all discussions and interactions with the client and persons/services involved in the provision of support including referral information, telephone and email correspondence
A record of non-attendance (by either you or your client) at scheduled and agreed meetings or activities
Evidence that you and your client have discussed your respective legal and ethical responsibilities — such as client rights and responsibilities, informed consent, confidentiality and privacy, professional boundaries, freedom of information, etc.
In addition to these broad guidelines, experts also recommend including the following specific pieces of information in each case note:
Topics discussed during the session
How the session related to the treatment plan
How the treatment plan goals and objectives are being met
Interventions and techniques used during the session and their effectiveness
Progress or setbacks
Signs, symptoms and any increase or decrease in the severity of behaviors as they relate to any diagnosis used
Homework assigned, results and compliance
The client’s current strengths and challenges
Additionally, the following have to be included in case notes:
Prognosis and treatment plan
Progress to date
Dates of service
Who attended the sessions
Financial issues (billing, costs, payments, etc.)
This may seem like a lot of information to present, but case notes with this data will help document not only what took place in the session, but also your decision-making process and how you implemented treatment and intervention