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
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Good Case Notes

• represent the clients 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

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Documentation is Critical

• to clients and family members
• to health care professional
• to employers and managed care companies
• to licensing and accreditation agencies

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Types of Case Notes

• DART
• Description
• Assessment
• Response
• Treatment plan

• DAP
• Description
• Assessment
• Plan

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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

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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

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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

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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.

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Behavior goals should be

• measurable
• observable
• of specific duration
• achievable
• relevant to the problem
• appropriate and consistent with client values

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Essentials of Record-Keeping

• Be thorough yet concise.
• Write clear, objective descriptions.
• Write notes immediately after the session.
• Proofread, but dont erase information.
• Consider how the client is portrayed.
• Use respectful terminology and avoid jargon.

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Be Careful with Wording

• Respectful language
• Nonjudgmental writing
• Clear description
• Key terminology

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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.

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Nonjudgmental Writing

• Use
• shows little motivation
• resistant/determined
• uses profanity
• shows passive behavior

• Instead of
• lazy
• stubborn
• foul-mouthed
• just sits there

Poor He looks and smells like he hasnt
bathed in days. Better He has poor hygiene.
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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.

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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.

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Maintaining Records

• Sign and date every entry.
• Store the case notes securely.
• Maintain confidentiality.