Case Notes Templates for Social Work

The National Association of Social Workers outlines the standards that every social worker must adhere to when practicing in the field. These twelve standards are critical to understand and implement to ensure that each practitioner treats all their clients fairly, secures accurate treatment, and works diligently to find the best solutions.

Today’s topic falls under Standard 10: Record Keeping. For this directive, the NASW says that “The social work case manager shall document all case management activities in the appropriate client record in a timely manner. Social work documentation shall be recorded on paper or electronically and shall be prepared, completed, secured, maintained, and disclosed in accordance with regulatory, legislative, statutory, and organizational requirements.”

Case notes in social work are used to follow a patient’s progress and ensure that everyone involved in their case understands what they need, the services to be provided, and how they’re doing with the decided treatment. Even though case notes can sometimes be dismissed as unimportant, they’re absolutely critical to ensure that no stone goes unturned when providing for clients.

Social Work Terminology for Case Notes

The practitioner needs to use the appropriate social work industry jargon so that every case worker on the project understands what is going on. Keep the social work dictionary on hand from the University of Montana when you’re first starting out so that you can refer to it as needed to create definitive, factual case notes. Common words and their definitions used over and over include:

• Adult Protective Services (APS): The system of options provided to adults most likely to experience abuse or neglect
• Attachment Disorder: A mental condition where children and young adults are unable to emotionally bond with caretakers due to experiences earlier in their youth.
• Benchmark: A standard to measure improvement or worsening of care or a condition.
• Bias: A negative attitude or belief about a person or group. Can be known or unknown.
• Caseload: The amount of people or projects that a social worker is responsible for.

When writing case notes, it’s important to use proper verbiage when writing about what a patient needs and assessing their case. Use strong action verbs, such as the following:

• Advised
• Advocated
• Suggested
• Highlighted
• Communicated
• Demonstrated
• Analyzed

Social Work Case Notes Templates

When tackling case notes, there are five short-hand social work case notes examples that people use to format their notes and accurately depict the services completed and what needs to be done in the future. While an individual social worker may have their own preference, it’s important to note that certain providers or organizations have a standard set of social work case notes that they require. Always use the preferred method of your organization (if applicable).

Social Work Case Notes: DAP

The DAP format stands for Data, Assessment, and Plan. It’s one of the most popular options for shorter notes that get straight to the point of what the client needs. This method is often used in psychotherapy and counseling.

If using the DAP case note format for social work, your notes will fall into the following three sections.

Data

This includes the information collected from a therapy session or visit with a client. Include critical information such as symptoms, important events, living situations, how the client was speaking or acting, and any other critical information needed to understand their circumstances and needs. This section should be as objective as possible. You are gathering facts, not stating your opinion on the condition. Add client quotes if applicable.

Questions to ask yourself for this section include:

• Why does the client say they came in or needed this appointment?
• What are the symptoms they are experiencing?
• How are they responding to treatment? Are they following through on the suggestions provided in the last session?

Assessment

This section is the critical analysis of the data you collected. From all the signs the client showed, you’re interpreting what this means and what problems they’re facing. This is where you’re writing your opinion.

Questions to ask yourself for this section include:

• What are the actual problems they’re facing?
• How did they do compared to the last time you saw them?
• Where are they at with their goals?
• Are there self-harm concerns for themselves or others?

Plan

Once the assessment is completed, you can make adjustments to their future treatment plan. There could be no changes and they’re on track. Or, you may need to add a service or move up the next appointment if the client is struggling. To note, this doesn’t change their entire treatment plan but rather makes small changes for continual improvement.

Questions to ask yourself for this section include:

• What does the client need to work on between now and the next session?
• What are the changes needed in the treatment plan?
• What other providers need to be notified?

Social Work Case Notes: BIRP

Another type of note popular among mental health professionals is BIRP, which stands for Behavior, Intervention, Response, and Plan. These notes allow for easy communication between providers for an individual who may have multiple case workers or mental health experts that they see.

If using the BIRP format, your notes will fall into the following four sections. Refer to the handy BIRP note checklist from Alameda County Behavioral Health Services as well.

Behavior

This section highlights the actions the clients are making that made them come to the appointment. This is the problem that the client is dealing with that they need your help with. For example, if someone’s depressed, the behavior could be that they have a hard time sleeping or paying attention at work.

Questions to ask yourself for this section include:

• What are the client’s behaviors during the visit? Were they dismissive, engaged, etc.
• How did the client say that they were feeling?
• Is the client making progress with their treatment goals?

Intervention

This section focuses on your treatment goals and methods for the client. Based on the action items written in the behavior section, outline how you’re intervening on behalf of the client and helping them heal. Use the action words mentioned in the previous section to detail what you’re doing.

Questions to ask yourself for this section include:

• What are the questions you asked the client?
• How did you act as a professional while interacting with the client?
• What are your treatment methods and how are they impacting the client’s goals?

Response

The response is not yours, but rather how the client responded to your treatment intervention suggestions. This helps all the practitioners understand how likely the client is to follow through with treatment and if it’s the right choice. Ideally, the client will be excited about the options you presented to them, but that’s not always the case.

Questions to ask yourself for this section include:

• How did they respond to your intervention suggestions? Be specific about their reactions.
• What were their questions, feelings, and thoughts?

Plan

The final section creates a follow-up of what needs to happen next for the client. Usually, this is the next time you’re seeing the client. Decide how much time is needed between the next appointment and what the client should be working on in the meantime.

Questions to ask yourself for this section include:

• How eager is the client to continue treatment?
• Did they complete the tasks assigned from the last session?
• What do they need to do between now and the next time I see them?
• Are there any changes in their treatment plan that I need to address?

Social Work Case Notes: SOAP

A popular format for healthcare providers and case workers, the SOAP format stands for Subjective, Objective, Assessment, and Plan. This type of note-taking gives way to subject and objective facts in different columns, making it easier for all types of professionals to see the larger picture of a client’s needs.

Some institutions even argue that the framework APSO works even better. This puts the assessment and plan first, which some argue is more important to read first. It helps practitioners who are in a hurry when reading notes to understand what treatments are being implemented.

For a great example of SOAP social work case notes, check out the link to Path Mental Health’s one from a therapist telehealth session.

Subjective

Every note in this section is subjective, meaning that it’s not based on hard facts. This is extremely important because it’s all about the patient’s experience and any guardian’s or attendees’ feedback. This covers what they came in for, symptoms they may be experiencing, and how they feel about their treatment plan. Ideally, you want to help them tell you their “chief complaint,” or why they came in to see you.

Questions to ask for this section include:

• What are your symptoms and how long have they been going on?
• What are your goals and feelings? If you’ve seen them before, are they happy with their treatment plan?
• What other health-related issues are you experiencing?

Objective

The next section is all about objective facts. This is measurable data that comes from conclusive places, such as a lab report or case management software. These are not symptoms that the patient is experiencing, but rather signs that can be proven.

Instead of asking yourself questions for this section, make notes based on hard information you have on the client available to you and draw conclusions from that.

Assessment

Next, you’ll create an assessment based on the signs and symptoms noted in the previous section. For caseworkers with mental health experience such as a licensed clinical social worker, use the DSM to guide you as needed on recommendations for a diagnosis.

Plan

Finally, the plan outlines recommendations for treatment and services to address the patient’s needs. This is very important to explain clearly and in detail so that providers who will read the notes after you understand how to act and what’s best for the client.

Organize Social Work Case Notes Effectively With PlanStreet

When clients have multiple case workers, mental health professionals, and other healthcare aides, it’s critical that they’re all able to communicate their case notes efficiently and effectively. Organize case notes in case management software such as PlanStreet.

Our system offers customizable forms so that you can take case notes in any of the social work case notes formats mentioned above. It’s HIPAA-compliant and stores confidential client information safely and securely. Plus, it allows for easy access to approved users because it’s a web-based platform.

Ensure that all practitioners have access to the case notes they need to best serve your clients with PlanStreet. To learn more, schedule a live demo with our team today.