Guidelines For Social Work Case Management Documentation
Guidelines For Social Work Case Management Documentation
Social workers should take reasonable steps to ensure that documentation in records is accurate and reflects the services
provided.
b.
Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to
ensure continuity of services provided to clients in the future.
c.
Social workers' documentation should protect clients' privacy to the extent that is possible and appropriate and should include
only information that is directly relevant to the delivery of services.
d.
Social workers should store records following the termination of services to ensure reasonable future access. Records should
be maintained for the number of years required by state statutes or relevant contracts.
Documentation follows the agency/organization/state or other governing body protocols and these are followed in the
charting. There may be differences in states; know state requirements.
Documentation reflects any significant client, family or ancillary service provider contact
Documentation is sufficiently detailed and organized to enable another social worker to assume work with the client at any
time.
Mark any error with a single line and initials never use correction fluid or tape
Always explain to client documentation process and share with client when possible/appropriate (consider cultural concerns
and history in response to "secrecy" of documentation)
Use a professional writing style avoiding jargon, using shorter words with precise meanings, writing short paragraphs
focused on a single concept
Do not just report facts as you have been told. Instead, specify where the information came from (client reports/states, client
is diagnosed with,)
Each page should have clients name or identification and include a confidentiality notice
Use Clinicians Thesaurus or other documentation resource. READ READ READ read other professionals progress/case
notes.
What to avoid
Do not diagnose if the client does not have a clinical diagnosis (client is depressed, rather say client states that he is having
feelings of sadness or depressed mood). OR describe symptoms (client describes seeing hallucinationsor is feeling sad on a
daily basis)
Completed documentation within 48 hours of meeting and supporting documentation should be included within 30
days (i.e proof of income).
Client should receive a copy of any work completed together and signed
referral reasons/process
behavioral observations
family history
support system
education/employment
financial/insurance
medications/medical concerns
coping behaviors
legal issues
advance directives
client/family goals
clinical assessment
violence/suicidality history
spiritual/cultural factors
Progress Notes
Always dated by contact/intervention (If writing late state late entry. If adding information state addendum to note dated
XX/XX/XXXX)
Outline reason for contact (client called requesting..., CM conducted scheduled home visit...)
Write in third person and refer to all individuals by title (client, case manager, sister of client, nurse, housing manager)
Write in present tense and identify source for material that is controversial/potentially untrue/client perception. For
example, The client describes her parents as severe alcoholics rather than the clients parents were alcoholics.
Describe client mood, affect, symptoms using client words first, then professional impression
Always end notes with plan (CM will send referral, client will meet with housing CM...)
NOTES ON USAGE
/c
With
/s or w/o
Without
ADLs or
Activities of
Daily Living
AMA
CC
Chief Complaint OR
Courtesy Copy
Clt or ct
Client
CM or SW
d/c
Discontinued
D/ch
Discharged
D/O
disorder
DNKA
DOB/DOD
Dx
Diagnosis
ETOH
Alcohol
Hx or h/o
History or history of
IDU,
intravenous
drug use
Usually used in
substance abuse or
HIV risk assessment
IEP
Used in schools
LD
Learning disabled
LEP
MDT
Multidisciplinary team
Medication
Regimens
mouth/oral
h.s. = at bedtime i.v. = intravenous
MH
Mental health
MSE
Mental Status
Exam/Evaluation
MSM
NOS
Usually used in
mental health
evaluation or
diagnosis
PLWH or
PLWA
Usually used in
advocacy work
PRN
As needed
Uusually referring to
medical care
R/O
Rule Out
Usually referring to
DSM-IV diagnosis
Rx or Tx
Treatment or Therapy
SEM/SED
SMR/PMR
Severely/profoundly
mentally retarded
SPMI
SSN
Sx
Symptom
w/d
Withdrawal
Confidential Progress
Notes
Date
Contact Notes
06/04/03 CC
06/05/03 AV
conversation comfortably.
During initial assessment, ct was unclear on the reason
for referral and stated that his doctor told him that he
needed CM services (Dr. John Smith with XYZ medical
center see referral form). Cm and ct discussed ctdefined problems, formed descriptive problems
statements and completed strengths assessment (see
assessment form). Ct was uncomfortable with
identifying own strengths and supports. CM assisted
with education about Strengths Perspective style of
Case Management and the role and purpose of the
services offered by ABC agency. Ct agreed that he
wanted to access services (concurrent with doctor
referral).
Ct described his history of homelessness since
childhood and survival skills used. Ct stated that he
prefers not to access homeless shelters and his
experiences with such housing services included having
belongings stolen and or defaced. Ct indicates that he
often lives temporarily with friends and acquaintances
that he has met on the street and at shelters. Ct is often
expected to pay for this temporary housing through
food, alcohol or illegal drugs (marijuana and crack). Ct
does not have a regular employment or paycheck from
work error MW-- income source but has worked for
temporary labor agencies and has done work for cash.
Ct stated that when he is lacking on resources he knows
how to find income source (usually limited, not
reported, and include both legal/illegal work). Ct
denied substance abuse concerns, but uses some sort of
drug at least 3x per week. Ct stated that substance use
does not affect with ADLs however has been denied
medical appointments at least 4 times due to being
drunk or high. Ct has also been asked to leave formal
temporary housing programs due to substance use. Ct
feels that this is unfair and was not able to access
needed medical care or formal housing programs.
Confidential Progress
Notes
Date
Conta
ct
Notes
Continued
from06/05/
04
Continued
-------------------------------------------------------------------------Ct denies any legal problems related to substance use
or other activity. Ct described limited contact to
family and asked to avoid any discussion on exploring
family relations as informal supports or as a resource
for support or housing........................more description
of assessment appointment, client needs, deficits in
resources, strengths, formal and informal supports and
needs................................................................
See Goal Planning worksheet completed by both ct
and CM at this appointment. Ct will indicated interest
in Shelter Plus Care housing program, but did not
want to commit today. -----------------------------PLAN: Cm and Ct will work on application next
appointment. Ct has two medical appointments
scheduled and has committed to abstaining from
alcohol/drug use before each appointment. Ct and CM
strategized that this is more realistic for morning
appointments; CM will assist in rescheduling 6/14/04
appointment for a morning time slot. Ct agreed to
contact Cm next Tuesday (06/08/04) to discuss
eligibility for other support programs offered by ABC
including the mens luncheon support program for
homeless men. Ct indicated no other concerns or
expectations at this time, but agreed to further
conversations about goal planning at next meeting.
CM will fax applications completed today including
bus pass and lunch pass
applications. ...............................................................
Miracle Worker, BSW
06/09/04
No
Ct did not contact CM as agreed upon in last meeting
Contac (agreed for 06/08/04). CM sent letter to temporary
t
address left by ct. reminding him of medical
appointment that was rescheduled on 06/14/04 (see
letter copy in chart---Miracle Worker, BSW