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Confidentiality, Case Notes and Court

by Casebook Editorial Team 1 min read

Do you have a love-hate relationship with your case notes? They are time-consuming at best. They may be a constant source of tension within your agency due to the pressure on providers to submit notes that meet third-payer standards to insure your agency gets paid in full and promptly. They may feel like an intrusion on your time with your clients.

Do you have a love-hate relationship with your case notes? They are time-consuming at best. They may be a constant source of tension within your agency due to the pressure on providers to submit notes that meet third-payer standards to insure your agency gets paid in full and promptly. They may feel like an intrusion on your time with your clients.

But what would you do without them? They are a record of everything related to progress with your clients. What you observed the first day, each intervention and their reaction, and they are key to planning the next logical step  in services and care you provide. 

Why Build Case Notes?

1. The why and how of services

“Because I said so,” only works for parents. No insurance provider, and certainly no judge, would accept such a simple statement to defend against a complaint. You must have a rationale for how you arrived at your determinations. Case notes, at their most fundamental level, document a client’s need for a service and the effects of that service. Anyone questioning your rationale should be able to follow your notes, and show how you arrived at your recommendations and decisions.

Good case notes explain your reasoning for your assessment/identification of the problem. They identify each finding that contributes to your ultimate analysis. They fit into the puzzle that includes every observation, recommendation, intervention, collaboration and outcome. You can zoom out to review the entire file or narrow it down to just one entry.

2. Avoiding misunderstandings

Good communications with clients drive your success in helping them, and good communications involves not just what is said, but also addresses anyone’s assertion about what was not said. 

The need to set firm boundaries with clients is a message you have heard repeatedly. Demonstrating you maintained such boundaries is another question. 

Case notes can describe: 

  • When you discussed boundaries with a client

  • Situations which threatened your boundaries and how you handled them

  • Observation that your client understood the boundaries

Well written case notes also describe your client’s state of mind at the time of any interaction you have. This detail can be helpful in many ways later on, particularly if they later file a complaint. 

3. Set expectations

Setting realistic expectations is another factor of good communication. Your client cannot meet expectations that have not been laid out clearly. Your agency is likely to have certain standards that apply to all clients; what happens if they are tardy to appointments, failure to show for appointments, failure to show repeatedly, failure to pay co-pays. These are just a few examples of agency-wide expectations.

Your case notes can reflect expectations agreed-upon at the level of your individual client. Often this will refer to agreements you make with clients about steps that can help them achieve their goals.  Another way to look at this might be what recommendations you made to your clients and how they responded. This is a key to defending against complaints. Of course, someone registering a complaint against you commonly will make statements that put you in the worst light and claim you never made a recommendation.

Consider an example situation. You work with Dave, who is able to manage mild paranoia except in public encounters. He proudly reports he obtained a job working as a cashier. You wish him well but you and Dave also had a prior discussion about the types of work environments best suited to his needs. You suggested that he might be happier working in roles that did not include direct customer contact. Now it is your job to help him make the best of it. You can also chronicle your discussions and advice. Later, if the job does not work out for Dave he cannot make an unsubstantiated claim that you steered him towards such a job or that you did not do your best to help him achieve success.  

When you itemize each recommendation, and notate the client’s response you will have a true record of what transpired. This is a contemporaneous record, giving it more credibility than an oral recollection or note made after the fact. 

4. Limits on Touch

Being sensitive to limits on touch is part and parcel of setting boundaries. It’s good that society in general has recognized that what is innocent to one person may not be acceptable to another. Protecting one’s personal space is an absolute right.

But social services workers will be with clients in times of success and disappointment. There will be times that a person welcomes a pat on the back or a hand on the shoulder. There is no better way to understand your clients’ perspectives than to ask, and then document the discussion. 

5. Backup for Insurance and Billings 

Third-party payers depend upon case notes to justify payment. Your notes tell them the service:

  • Actually happened.

  • What you delivered

  • It is reasonable to believe the service can lead to the kinds of results from the services for which insurers are paying. 

What constitutes a solid case note?

Accrediting agencies such as the Commission on Accreditation for Rehabilitation Facilities (CARF), third-party payers such as insurance companies, and managed care organizations maintain specific documentation requirements to ensure accountability. 

1. Features of good case notes 

How will you know a case note when you see it? The clues should be in the record, even if it is only a few short sentences. Features of good case notes include:

  • They will be accurate and complete, with relevant details of the interaction. Write it as if a colleague would need to use it to follow up on a client, without any chance to ask you questions. 

  • Focus on what is relevant to your client’s progress toward goals. 

  • Always, always, always, date and sign the note. A note will not be considered contemporaneous if you have let it slip by without the date of the interaction and your signature attesting to it.

  • Be clear and concise. Get in the habit of checking your spelling; bookmark your dictionary app and wear out the icon clicking on it. Get in the habit of using a thesaurus. And finally, review the basics of good grammar. Using bullet points and short sentences will help you achieve clarity. 

  • There is no firm and fast rule on the amount of detail so use common sense. Include only relevant details needed for the reader to understand your point and the note’s context. 

  • Have you ever gone back to your notes and even you couldn’t read them? What if one of those notes is key to a complaint filed against you? Illegible notes won’t help. One of the best facets of using case management software is your ability to input your notes by computer – meaning you can type them in. If you have to hand write your notes during the day, then input them as soon as you can while they are fresh on your mind. And remember the rule above; be clear and concise. 

  • Write each note for its part in achieving the goal you hope to see your client reach. Each action you take is part of the “grander” plan so make it clear in the note itself. 

  • Maintaining good notes is part of your overall strategy, and reviewing them on a regular basis allows you to evaluate the client’s status on their progress. Good case management software will allow you to set reminders in your calendar to perform regular reviews. 

2. The No Nos of Good Notes 

If you want notes to defend you against complaints, then it’s just as important to be clear about what to avoid in how you draft them. 

  • Read them aloud. Remember, your notes are literally your voice. Read them aloud to yourself, and ask if that is how you would want to sound in a room full of people asking questions about your ethics or actions. 

  • Avoid Generalizations. What if your notes about Dave and his new job as a cashier were to say “People like Dave should never have to meet new people?” Imagine how it would sound if you wrote that all people with paranoia should stay away from all social situations. Look at the words “never” and “all” and you find your culprits of generalization. Every person’s situation is unique, and what may be appropriate for one may not be appropriate for others. Don’t write notes that suggest you see no differences among people, whatever issues they face.

  • Avoid the use of abbreviations except for the most common.  There seems to be an infinite collection of abbreviations and acronyms that you could sprinkle through your notes. Don’t. If you need to repeat a name or designation to avoid confusion then it is the right thing to do. Your notes don’t have to read like Hemingway; they need only to be clear.

  • Avoid casual interpretations. Do not throw casual observations into any part of your case file. Only add your thoughts that have meaning for your clients and their journeys. 

  • Avoid signs of bias, prejudice, or negativity. Even the most fair minded may make case notes that carry unfortunate biases or prejudices. A clumsy turn of phrase could rebrand your reputation as a person carrying negative attitudes. Never sign and date your notes until you have reviewed them for your intent. 

  • Avoid writing any unverified finding as to the nature of a client’s problems. If you discover an issue that has gone unrecognized so far treat it as an issue to explore. 

Using Case Notes to Protect Information

Are you ever tempted to discuss a particularly unnerving or fascinating situation you have encountered through your work? If you are a social worker there’s a good chance it fascinates you to know what makes people tick. At the same time it could be fatal to your career to breach confidentiality. That is a message drummed into those who work in human services. And such a breach can put you in the most legal jeopardy and be the hardest kind of case to defend. 

It may be surprising to turn to case notes as a tool to protect confidentiality, and the protection that they give your reputation and career. The client file should always be a secure location to put any piece of information relevant to a particular client – case notes from interactions, attachments, forms, reminders, etc. Robust case management software offers the best security for your records, but whatever form you use it should be easy to maintain and tough for others to see.

We can take some tips about confidentiality from the Health Insurance Portability and Accountability Act (HIPAA). The Act was written specifically (in 1996) to create national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. And though its protections are written specifically for health information, non-medical social services agencies often follow its standards. After all, when you work with a person or family with complex needs you may engage with health care providers who are specifically covered under the Act.

Whenever possible, get it verbally and in writing. We all sign things without reading them. (Terms and conditions for software apps and insurance documents come to mind.)  

1. Information going to third party payers. 

Think about misunderstandings your clients might have about any information you reveal to third-party payers. Plan to educate your clients about what third-party payers need, and why they need it. 

More than likely your agency intake routinely requires that clients sign a consent to release information about their circumstances, both health and non-health related. Don’t assume that a signature means the client read it. They may be genuinely surprised if they learn information was shared. Confirm their understanding and make a case note.

2. Contact outside of your service provider-client relationship. 

Let your clients know what will happen if you see them outside of service related interactions. Some social workers make it a policy to look the other way. This prevents any chance others will pick up on the nature of your relationship. Have a plan ready so no one is offended. At the least it gives your client the opportunity to say they prefer the risk over feeling ignored. Either way, write it, date it, sign it.

3. Keep information sharing succinct and limited to absolute necessity.

When you need to share information make a case note about why. Then keep the shared information as succinct as possible so that it’s clear what you shared was related specifically to the rationale.

4. Inform your client.

If anything happens to confidential data, document the incident in each client file that may have been affected. Inform your client immediately as to what happened, how it happened, and what’s being done to correct the problem and prevent future risks.  

The Elephant in the Room: Duty to Report

There are times it also can be fatal to your career not to disclose information that might appear like it should be protected. The Federal Child Abuse Prevention and Treatment Act (CAPTA) requires each state to have provisions that require certain individuals to report known or suspected instances of child abuse and neglect. You must report your concerns when you have a reasonable cause to suspect, or you have a reason to suspect, a child is or has been abused or neglected. You do not have to prove the abuse or neglect but you must have reasonable grounds for your concerns. A record you make, contemporaneously, with each incident setting off your alarm bells, should reflect what you suspect and why you suspect it with all relevant details.  

There are situations when you have an ethical obligation to report credible threats of harm made by someone towards themselves or others. Professionals in many fields, particularly mental health care and law enforcement, may have this kind of duty to report. If you are unsure if you have a legal duty, consult your state’s licensing authorities or check this resource by the National Conference of State Legislatures.

Duties to report may be mandatory, giving you the right to report information given to you in confidentiality without risking your reputation or career. Many situations may not be entirely clear. Either way, it is always a benefit to you to write detailed, contemporaneous, signed and dated case notes.

Case notes are an essential part of best practices for social services workers, not to mention a requirement of their jobs. But they play another vital role as well. In the event a complaint is filed against you, your case notes can be your most powerful tool to show complaints are unfounded. Next time you want to race through your notes as a tedious task, remember they are essential to your reputation and career.


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Casebook Editorial Team