Writing Effective Case Notes: A Comprehensive Guide, Lecture notes of Toxicology

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Effective Case Note Guide

Important To Remember:

 Case notes should always be written in third person: “This writer” or “This case

manager” conducted a home visit with client, Ms. Jackson…

What should a good case note include?

 Facts : Include facts about your encounter with the client. Case notes must include the name of

the client, the date and time of the meeting or visit as well as the location of the meeting. If the encounter with the client occurred via phone, the case note must include whether or not the client was contacted or if the client made contact. Case notes should also include the name and title of the person submitting the case note.

 Purpose : Case notes must clearly explain the reason you are interacting with the client. State

whether or not the encounter is a follow-up meeting, monthly or weekly scheduled meeting, unit inspection, intake, exit meeting, and/or to obtain or provide information to the client.

 Observations: Case notes must include clear observations of the encounter with the client.

If completing a home visit or unit inspection, state whether or not the Housing and Participant Assessment Report (HPAR) was completed. (Please be advised that HPAR assessments are only required for scattered site programs). State whether or not anyone else was present in the home or unit. Clearly describe the condition of the home, room or unit (i., e State whether or not the unit was free from excess trash, whether or not kitchen stoves, counters and floors were free from food debris..etc. ). State whether or not any maintenance concerns were observed. If the encounter is occurring in an office setting or somewhere other than the client’s home, room, or unit, include whether or not the client was accompanied by someone; if so, state the person’s relationship to the client. Describe your observations on the client’s mental health state. In this section, it is important to note if the client “appeared” to be under the influence of a substance.  When noting that a client appeared to be under the influence of a substance, you should always state “It appeared” rather than stating a claim such as “The client was intoxicated”. Stating that a client was under the influence in a case note is only acceptable if there is documented proof, such as if the client took a toxicology screening and it yielded positive results. For encounters that are in person with a client, you must also state your observations about the client’s child(ren) if they are present.

 Occurrence: Cleary state what occurred during your encounter with the client. Include what

was discussed, what goals were discussed and what action steps were put in place, whether or not resources were provided and/or whether or not resources were requested?

 Plan: Clearly describe next steps. State whether or not the next meeting or follow up with the

client was scheduled. If so, provide the location and time of the next meeting. State the purpose and/or goal for the next encounter with the client. Clearly identify roles and responsibilities for

both the client and case manger in preparation for the next encounter with the client: “The case Manager will……..by this date….The client will……by this date…..”.(Please note that the “Action Step” section of a case plan in HMIS is a good way to identify and track roles and responsibilities for clients and a good way to tie that responsibility to a due date. Please be advised that at all clients must have at least once action step in progress per open. This is required for all program types in HMIS).

Example of a bad case note:

Case manager met with the client for a home visit. The client was not home alone. The case manager spoke with Ms. George about finding a job. Ms. George will continue to keep in contact with her case manager.

Example of a good case note:

Angela Lewis, FRSP case manager, met with Ms. George at her home on 10/2 4 /2019 at 10:00am for her scheduled monthly home visit. Ms. George was home alone at the time of the home visit as she reported that her children were at school. Ms. George appeared to be in an overall good mood at the time of the visit and was very engaged. Her apartment was free from excess trash and the client’s kitchen was free from excess food debris at the time of the visit. There also appeared to be no maintenance concerns in the unit. During the home visit with Ms. George today, the writer completed and reviewed the Housing and Participation Assessment Report (HPAR) and also assisted Ms. George with completing her monthly budget. The writer engaged Ms. George in a conversation about her progress with her goal of increasing her income. Ms. George shared that she completed about three job applications this month which included: Starbucks, Target and Marshalls. She reported that she has not yet heard back from Marshalls or Target, but shared that Starbucks contacted her for an interview which is scheduled for November 5th^ 2019 at 2pm. Ms. George confirmed that she will attend her job interview with Starbucks at 2pm on 11/5/2019 and also reported that she will continue to use Indeed.com as her method of searching and applying for jobs. In addition to continuing her job search, the writer suggested that Ms. George also contact Marshalls and Target in effort to follow up on the status of her applications in which Ms. George agreed to do so. Ms. George shared her goal to apply for a total of 6 jobs during the month of November. Ms. George is scheduled for a follow up phone call with the writer on 11/15/ at 11am regarding her progress with her job search.

Protecting the Client’s Privacy in a Case Note

While it is important to be as descriptive as possible in a case note, it is also important to protect the client’s privacy. The following are topics with sensitive information that should be properly addressed in a case note in effort to protect the client’s privacy:  Legal Information A client may share information with you about their legal status (i.e whether or not they are on probation, information about their criminal record..etc). In effort to protect the client’s privacy regarding a legal matter, instead of disclosing specific information