Case Notes Best Practices: Writing Notes That Hold Up

Case notes are the record of the work. They help the next worker pick up where you left off, show funders what was provided, and protect both the client and the agency. A simple rule applies: if it is not documented, it is hard to show it happened.

What a good note includes

• Date, time, type, and length of the contact
• Who was present and where it took place
• The purpose of the contact
• What was discussed and what you did
• The client's response
• The plan and next steps, with dates
• Your name and role

Be objective

Write what you saw and heard, not your conclusions about it.

• Instead of "Client was drunk," write "Client's speech was slurred and there was an odor of alcohol."
• Instead of "Client was uncooperative," write "Client declined to complete the application and said, 'I'm not doing this today.'"

Use quotation marks for the client's exact words.

Be timely

Write notes the same day whenever possible. Details fade quickly, and most contracts set a deadline for entry.

Be relevant

Include what relates to the client's goals and services. Leave out gossip, personal opinions, and unnecessary detail about third parties.

Common structures

Many agencies use a format such as DAP (Data, Assessment, Plan) or SOAP (Subjective, Objective, Assessment, Plan). Use the format your agency requires, and be consistent.

Write as if the client will read it

Clients can often request their records. Respectful, factual language is always the right choice.

Common mistakes

• Vague notes: "Met with client. Doing well."
• Copying and pasting the same note
• Missing follow-up on a plan from the last note
• Late entries with no explanation

Check your own files

Review a few of your own files each month. For an outside review, our Quality Assurance service checks documentation from intake forms to discharge papers.