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.