It’s no secret that casenotes are not at the top of social workers’ favorites list. Documentation in social work requires timely and thorough casenotes which, at times, may seem like an obstacle to social workers’ direct work with clients. It’s not uncommon therefore for workers to question the value of casenotes and seasoned peers might even advise shortcuts. I’d like to offer a different view of casenotes, however, drawn from a pivotal experience that I had in the field. The following case example demonstrates just how consequential casenotes can be.
Case Example
“She called the police on me! She called the freaking police!” That was the voice of my client Rebecca* screaming to me across the phone. Rebecca was a Caucasian woman in her 40s who was typically a bit standoffish during our meetings but always pleasant. She’d been diagnosed with Schizoaffective Disorder since her 20s and she also had an informal mild Intellectual Disability. Rebecca stated that she told one of her support workers that she wanted to blow up a building. “I did want to; they take so long with the darn prescriptions. But I didn’t mean it seriously; it was a joke!” she explained. Her time to talk was limited however because the police arrived shortly afterwards. The police charged Rebecca with making a bomb threat, threatening mass violence, and they took Rebecca to jail.
When Casenotes Help to Determine Client Outcomes
Documentation in social work is a critical skill and many workers in the field are advised that their casenotes may be used in court one day. A high percentage have yet to have that happen, however. When my casenotes were suddenly summoned into court to help determine the mental capacity of my client, and ultimately her fate, whether she would be sentenced to federal prison, it was too late to try to edit, review, or complete any more of her casenotes. I could only hope that there was enough substantial information there to help advocate for my client.
In Rebecca’s case, my casenotes were called on to help determine mental competency and criminal responsibility. Your casenotes may be called on to help determine abuse, neglect, criminal responsibility, child placements or more, especially if you work in case management. When we recognize the power that our casenotes can have in clients’ lives, hopefully it causes us to pause, reflect, and be more intentional in our record-keeping. For some tips on improving your record-keeping and case management skills, please see these helpful posts from Casebook: Face Out of The Screen: Balancing Client Care With Documentation and Top 10 Essential Case Management Skills and How To Master Them.
“Thank you”
We don’t commonly think of documentation in social work as a service to our clients. We tend to focus on the unpleasant aspects of documentation but accurate comprehensive casenotes are a gift and a service to clients. The casenotes that I’d written for Rebecca enabled a judge to see her non-threatening nature & the impacts of her illness which ultimately led to her being deemed non-criminally responsible and released to a safe placement. Apart from legal matters, casenotes are also regularly used to make other important decisions that affect client outcomes. In case management for example, casenotes are frequently used for continuity of care. Within organizations, casenotes should offer a comprehensive record of a client’s interactions and services there. Clients often lament that they feel as if they have to “start over” whenever an organization experiences turnover; with good casenotes however, that is much less of a concern. Interagency transfers, referrals, and coordination with outside service providers all flow smoother when there’s detailed casenotes and an effective recordkeeping process in place.
How to Create Better CaseNotes For Your Clients
Rebecca’s case provided a powerful example of the implications of casenotes, and I hope her experience challenges and inspires you. It is possible to create more thorough, accurate casenotes that better support clients—and it can be done without costing you extra time! Enhancing your casenotes requires a two-pronged approach: 1) individual professional development, and 2) organizational support.
On an individual level, you can deepen your knowledge of the best documentation practices. Casebook offers insightful resources, such as the blog post “Confidentiality, Case Notes and Court” that explores what makes effective casenotes and how they support client care, continuity, and legal protection.
On an organizational level, investing in software that makes record-keeping intuitive and accessible can enhance casenote practices. Casebook specializes in data-management software tailored for human service organizations, simplifying documentation and ensuring seamless collaboration between team members. Using a centralized platform like Casebook ensures providers can maintain continuity of care, even when transitions between case workers occur. See how Casebook works.
*Name and details changed for privacy.
