1. Writing Case Notes A Collaborative Workshop presented by Child Development and Family Services and the Purdue Writing Lab

2. Good Case Notes • represent the client’s situation • provide a record of client care • enable an action to be taken based on their review • can be used in court, in school, by social agencies, and by insurance companies

3. Documentation is Critical • to clients and family members • to health care professional • to employers and managed care companies • to licensing and accreditation agencies

4. DART Description Assessment Response Treatment plan DAP Description Assessment Plan Types of Case Notes

5. DART Description of the problem and your observations Assessment of what may be going on Response, or record, of what you did or suggested Treatment plan, including goal setting

6. DAP Description of the content and the process of the session Assessment of what is going on Plan for what will be done in the next session and in the meantime

7. Descriptions include objective information when they report observable behavior seen by the therapist include subjective information when they report what the client says or feels

8. State behavior goals in terms of: Subject/Verb Action/Object Frequency Duration Mary will give her son positive reinforcement at least two times every day for a week. Planning and Behavior Goals

9. Behavior goals should be • measurable • observable • of specific duration • achievable • relevant to the problem • appropriate and consistent with client values

10. Essentials of Record-Keeping • Be thorough yet concise. • Write clear, objective descriptions. • Write notes immediately after the session. • Proofread, but don’t erase information. • Consider how the client is portrayed. • Use respectful terminology and avoid jargon.

11. Be Careful with Wording • Respectful language • Nonjudgmental writing • Clear description • Key terminology

12. Respectful Language For information such as race, gender, age, sexuality, and physical condition Poor: Pat is a 26-year-old handicapped woman. Good: Pat is a 26-year-old woman with a disability.

13. Use shows little motivation resistant/determined uses profanity shows passive behavior Instead of lazy stubborn foul-mouthed just sits there Nonjudgmental Writing Poor: He looks and smells like he hasn’t bathed in days. Better: He has poor hygiene.

14. Clear Description • Watch for misguiding, non-specific wording. • Show instead of tell. Poor: Chris was obviously nervous. Good: Chris was biting his nails and shifting in his seat.

15. Key Terminology • evidenced by • appears versus seems • client-active language • qualifying comments Poor: From her frown, Carol seems angry. Good: Carol appears angry, evidenced by her frown.

16. Maintaining Records • Sign and date every entry. • Store the case notes securely. • Maintain confidentiality.