Happy belated Valentine’s Day! If there’s anything that I love more than anything about my profession, it’s the documentation process! Case note writing is a
dreadful chore necessary task that is near and dear to my heart. Case note writing is a process in which we document:
- Interactions with our client
- Progress made towards goals
- Interpretations (“as evidenced by”) of our interaction with the client.
Conventional wisdom says that your hour with a client should be 50/10… a 50 minute meeting with 10 minutes for case notes. Ideally, most social workers would most like for notes to be as easy as a two minute jot-down before moving on with our lives. Still, most of us will wrest with the eternal struggle of balancing the task of documenting the bare minimum and essential information of a session. All without spending days upon days writing a dissertation on our work. These tips can also be applied to the papers I know you’re currently procrastinating on, too!
Here are a few methods I have tried and their end results.
1. Egg Timer Method
This is an old fashion method, but the “tic-tic-tic-tic” lets you know that your time is limited and acts as a psychological fire on your rear end. For me, the “tic-tic-tic-tic” is a reminder, telling me to hurry the heck up and finish before the timer has a chance to buzz. This totally beats a digital timer, hands down.
Ikea has the best timers at about $2.00 . The one above was about $7.00 at Bed, Bath, and Beyond.
Outcome: Stress-inducing, but for me, it gets the job done.
Read more helpful hints on how to jump-start your case note writing process, after the break!
2. Two Hits and a Miss Method
Make a short-playlist that has two songs that make up about 10 minutes worth of time followed by an embarrassing/dreadful/hated tune (e.g. Infamous Canadian Export Who Shall Not Be Named). Should you take more than ten minutes on your case note, you have to listen to horrible pop music until you finish your note.
Outcome: Embarrassment, decay of the soul, but a completed case note.
3. Just write.
There are times when writing a coherent case note is out of the question, but you can sow seeds for a case note: Even if you are drained after a client meeting, my best advice is to just write. My case notes are structured with different areas that I must address (i.e. Problem, Goal of session, Intervention, Client Response, Clinical Impression, Plan) and sometimes just getting out thoughts into the sections is enough to trigger my brain when revisiting those sections. For me, the Intervention part is the hardest to write. So I will just outline what I know happened.
When I revisit it later, I’ll rework it into:
- Discussed relationship types with client. Psychoeducation included cycle of violence, healthy vs. unhealthy relationships, and other strategies (Including use of “I” statements) to assist client in communicating with her partner. Client was engaged in these interventions and cried, stating feelings of shame for her own destructive communication styles.
All the other “stuff” that was there was re-triggered in my memory bank came up and I was able to put together a coherent sentence or three when I came back refreshed.
Outcome: Half-baked case notes, but with seeds that can flourish later.
4. Treat Yo Self
After going through a pile of case notes, what can you reward yourself with to make it worth your while?
5. Prioritize and Make a List
If I have more than one case note, I will make a list of my clients (initials only) and with a Sharpie, cross out each name as I finish it. I will prioritize notes (i.e. triage) that need to get done right away (e.g. higher risk clients) and then work my way down the list to lower-priority case notes.
Outcome: A completed list, triage clients, and self-satisfaction.
6. Revisit Your Structure
As previously mentioned, the structure that I use is the one that my employer has me using. Being that I memorized the order, I may have not fully remember what defines each section. This would be a good time to revisit your work site manual on what is asked in each part of a case note – It’s easy to wander off topic and to deviate from what is needed.
- “Intervention” may be simply defined as “What work did you do with the client?”
- “Clinical Impression” may be defined as “What was the client’s affect, mood, presentation and did it shift during session? State any risk(s) associated with client’s presentation and what measures were taken to address/resolve them. Discuss progress towards goals and client’s motivation level to meet goals. List any provisional diagnoses or changes in treatment goals, etc.”
If you have a case note structure at your work site, why not scan it to Evernote with your phone so you can pull it up easily instead of having to hunt for it later?
Outcome: Less fluff, More on-point.
7. Review Previous Notes
If you have had previous case note writing for your file or at your workplace, pull up case notes you have previously written. Being more experienced and in a different state of mind, you can absorb, look at, and feel the previous work you have accomplished and emulate, improve upon, and draw inspiration from it.
If you can look at how your colleague writes notes. In my experience, the manner in which licensed folks write their notes just tickles me with delight; I find their apt, to-the-point, no-nonsense case note writing is just refreshing.
Outcome: A self-reminder that you can and have written good case notes before.
8. Remember: It’s a case note, not a dissertation
If you follow me on Twitter, you will see that sometimes I am in case note h-e-double-hockey-sticks and I will tweet this out in jest.
If you find yourself writing too much, it might be time for a break. Like going to Twitter and complaining.
Take a five minute walk to clear your mind. Social work is hard work. It’s rewarding, but if you’re burning out, you won’t be able to function in full-burnout mode. Even if tired, you can be at your very-best-while-tired.
Outcome: Shorter and to-the-point case notes
9. Get comfortable
Getting comfortable in your office will reduce unnecessary stress. Switching into casual shoes (or none at all), stretching out some muscles, taking a short walk, preparing a cup of tea, taking a deep breath… Whatever brings your stress level down and alertness up.
You get bonus points if the shop is closed and you are at your job or internship site and you can get away with casual attire while finishing up. Super bonus points if that casual attire is work-out clothes. Super duper bonus points if you actually go work out in your workout clothes.
Outcome: Less-than-frayed nerves at the end of a stressful day
10. Get in a zone…
When we talk about Person in Environment, is yours working for you? What do you need to change to be more efficient at social working?
There is a fine line between procrastination and preparing your work environment for getting stuff done. If you do end up getting an egg timer, set it to three-to-five minutes to allow you to prepare.
Outcome: A pro-work environment! Efficacy, maximized!
What other tips would you add to this list?
When it comes to writing, I adhere to these rules:
- Presentation: Quality over quantity, shedding fluff whenever possible and having coherence.
- Direction: The writing task has a purpose (e.g. to inform, remind, document, etc.)
- Ethics: A subjective narrative that has facts (i.e. things we observed) that are supported with evidence. When you have an opinion or suspicion, you state it (e.g. “It is this clinician’s belief that [x], as supported by [y].”)