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HUS3350_Creating_Case_Notes_in_Human_Services1.pptx

Creating Case Notes in Human Services

The Purpose of Case Notes

Record details of the client interaction

Monitor progress of client

Document actions taken by client and recommendations proposed by the Human Services professional

Case Notes Include:

Current and accurate information

Concise details

Descriptions of the meeting and content involved

Objective, factual information

Assessment of the meeting

Suggested actions or plans for the client

Follow-up information

Case Notes - Poor Example

Client: Michael S.

Date: 1/9/2015

Michael S. didn’t stay in the center very long today. I think he did one or two tasks for work readiness but was nervous and frustrated with the computers. He smelled like cigarettes, too, so probably just needed a smoke. When he left he said he would come back another time so I told him to have a good weekend.

Case Notes – Good Example

Client: Tiffany L.

Date: 1/9/2015

Client attended her appointment with a career counselor on 1/6/15. Resume writing and vocational activities were reviewed with client. Ms. L. has completed 15 of her required 25 hours towards job skills training that need to be completed by 1/30/15. The childcare stipend was reviewed and issued to Main County. Transitional employment services will be discussed at the next appointment on 1/28/15 at 11am.

Important Reminders

Maintain objectivity

Use professional language

Include recommendations for future referrals if necessary

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