In social work, we write case notes and record information daily; part of record keeping.
Record keeping helps in planning and decision-making.
Maintaining high-quality social work case notes and recording fosters collaborative working relationship between the social worker, other professionals, and the adults/children they support.
A sample case note for social work will help you understand what makes a high-quality case note.
ALL YOU NEED TO KNOW ABOUT CASE NOTES
So, what is a case note?
A case note involves a social worker writing what they have done, what they have seen, their professional views, analysis of the situation and action plans.
As a result, writing, clear, concise and factual case notes is an essential skill for social workers to nurture.
As part of the Social Work Role, accurate record keeping is vital.
This means that if you feel your recording skills are not up to scratch, take steps to improve upon this as part of your own personal development.
A manager once said, “in social work practice it is vital to case note everything.
If you don’t write it down, then it didn’t happen!
If you don’t write it down, and it happens, then you are in trouble!”
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When you have a conversation with a service user, client, or have a case discussion with a manager or colleague, the best practice is to leave a case note.
Research shows that excellent record keeping and quality case notes help improve outcomes for service users/clients.
In addition, there is evidence to show that excellent record keeping / case note can help safeguard people.
Many organisational policies highlight the need for social workers keeping accurate records at all times.
However, with an increased case load coupled with time constraints, social workers often find it challenging keeping up with their case notes and record keeping.
In order not to fall behind with your case notes, I recommend you update the case records as soon as possible.
What is the importance of a case note or recording?
I highlight four of my top reasons for writing high-quality case notes.
1.0 Helps with reflection
Writing a case note is an essential part of the work we do in social work.
Most often it feels like an added task which could be skipped or handed over to the admin.
However, cultivating the habit of keeping an accurate record about a case helps us think through what we have done, and how best the individual can be supported.
Through writing case notes, you can reflect on what went well and what did not go so well regarding a particular situation.
2.0 It serves as evidence when needed in court.
Social workers often attend court to present cases or to support a service user or client.
Sometimes, they have to attend a court hearing even when given brief notice.
Having up-to-date case notes means you have readily available information and clear evidence to present to the court.
The case notes may also come in handy when there is a complaint or investigations required.
3.0 You have a record of the chronology of events
A chronology will provide a summary of significant events in a person’s life.
This means that you will have a record of significant concerns, risks or incidents that impact positively or negatively on a person’s wellbeing.
Such information is relevant in court proceedings and in child protection cases.
4.0 It supports good assessments
Good assessments should be holistic.
Holistic assessments encompass the physical; emotional; spiritual; mental; social; environmental.
It includes all aspects of wellbeing.
The importance of relationships, work and support network.
In addition, it involves gathering information from relevant sources with the client’s consent.
Information may be gathered from friends, family, or carers.
From this, you can identify important themes and challenges.
The process ends when the assessment outcomes are used to inform an individualised care and support plan.
With a clear and factual record keeping or case note, it ensures an effective and good assessment is carried out.
Good assessments also capture the wishes and feelings of the individual.
However, before you can record the wishes, feelings and views of service users or clients, you first need to spend enough time with them in order to know what they are.
This can only be achieved through forming rapport and having a meaningful professional relationship with the children or adults.
5.0 It is part of your professional duty as a social worker.
As a social worker, your duty includes keeping an accurate record.
It helps with accountability too.
Avoid the use of jargons and make your write up as personalised as possible.
That is why I choose to follow the following process recommended by Social Care Institute for Excellence (SCIE) when completing case notes in social work–PARTNERSHIP
How do you write a good case note?
It’s all about the person.
Ensure the case notes reflect the voice of the individual, what they hope to achieve from the assessment, review or in their lives.
Note the individual’s appearance, if relevant.
Review the information you have recorded to ensure that it is up to date and accurate.
Be honest, factual, and avoid being vague.
Read over what you have written and think about how it will make the service user or client feel should they read it themselves.
Will it cause them to feel distressed, upset or will they agree with what you have written?
4.0 Take detailed notes
Ensure notes taken during a conversation or assessment are detailed.
Record information timely.
Remember to schedule time to write your case notes.
5.0 No jargon
Use simple English language and avoid the use of jargons.
For example, you may write in a case note “the next MDT meeting is on the 7th of January”.
This may make sense to you, but will appear incomprehensible to others who do not understand the meaning of MDT (multi-disciplinary team).
Your opinion and professional views/judgement matter as a social worker.
However, make sure they are backed with facts and evidence.
Give reasons where possible.
Distinguish between facts and opinions, so opinion is not mistaken for fact.
Be self-aware, but take the time to judge the levels of risk and need effectively.
Remember to read historical case notes and assessments.
Be concise, brief, and avoid waffling.
Write what is necessary and leave out unnecessary details.
Make your writing objective.
Gather information from other relevant sources and record what other professionals are doing to support the service user or client.
This will also give the next person who reads the case recording a clear indication of what is going on with the case.
10.0 Identify any errors
Read over notes and identify any grammatical or spelling mistakes.
Ensure that you are following your organisational IT procedure too and record information on the system.
Part of your credibility as a social worker is to maintain accurate and clear records.
A social worker who is unable to provide a record of what they have done with a case or what their action plans are may be questioned about their professional ability.
Be mindful of your own views and unconscious biases.
Share information only on a need-to-know basis and with individual’s consent unless there are safeguarding concerns or there is a lack of capacity.
Write your action plan.
How do you write a case note in social work?
Case note examples in social work vary from one organisation to another depending on organisational policies and guidelines.
However, a case note should cover basic elements as highlighted in the PATERNERSHIP model above.
Using this model will help you write better case notes.
Case note template
Sample Case Notes for Social Work You Can Learn From
04/04/2021 at 10:30am. (this is the time the call/visit took place) Home visit to Beth to discuss children’s poor school attendance.
Beth expressed having no transport for children to attend school since her car broke down.
Beth said she was feeling low and would like to engage in some social activities.
X and Y were observed playing, and they told me they were looking forward to going back to school.
Discussed arranging for a school transport to drop children at school. With Beth’s consent, I spoke to the transport team and made a booking for children to attend school.
Agreed to visit Beth again on 07/04/2021 at 2:30pm to start looking at social activities that she could engage with (name, role).
04/04/2021 at 11:30am. (this is the time the call/visit took place). Home visit to Sally for a welfare check.
Sally said she had a seizure last night. I observed very little food in the house. I supported Sally to speak to the GP surgery. GP has booked Sally in for some blood tests and scans.
With Sally’s consent, I contacted the food bank and arranged for a food parcel to be delivered.
My views are that once I review Sally’s care and support needs, she will have the appropriate support in place to help with her day to day living.
Agreed to visit Sally again on 08/04/2021 at 3pm to review her care and support needs.
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
- Action plan
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