Writing case notes is a key skill for all social workers to cultivate. A quality case note requires good organization and clear analysis. Here are two tips for writing better consult notes. • Discuss common problems with case notes. • Identify the primary factor in writing a good case note. This video includes what case notes are and why good case notes are important, what makes a good case note, provides a structure for writing good case notes, and introduces the concept of the mental status observation, which can be useful in writing case notes. • Practice with real case notes. They all need to … Generally, a case note is divided into topical sections. Example Case Notes Remember the following principles when writing case notes: Clear Factual Relevant & related to employment Include employment goals, restrictions or accommodations if needed Should follow the SENSE model Example comments/case notes Demonstration of Progression and Sequencing Intake Note Intake sets the stage for all future documentation. Never write notes on a blank sheet, even if the notes are contained within the person’s file; always ensure identifiers are noted on each individual page. • List the three standards for determining if a case note is good. Be able to explain them and use them. 5. 2. By the end of a case study, the reader should be able to visualize themselves as the hero of their own story. Almost everything you need to write in an intake note is already completed in eCOMPAS during the assessment. Use a blue or black pen. The patient may need the consult note for insurance billing or to see share with additional physicians. Clear, concise notes. These writing skills are relevant regardless of the type of document you are writing. Consult notes are extremely important, so, as a physician, it's your responsibility to write a consult note that's useful and informative. • Know the seven elements that should be present with every case note. Just like a story, good case studies have a beginning, a middle, and an end, as well as a protagonist – your customer – overcoming a problem and achieving their objective, just like the main character of a story. Thoughtful, factual case notes document a client’s symptoms and progress, and can help govern treatment decisions. Benefits of a Great Case Management Documentation System. How is a case note organized? Develop and write your case study using the data collected throughout the research, interviewing and analysis processes. Beyond reading, you will be asked to explore and compare examples of good and bad case notes in context, edit and write case notes based on vignette scenarios provided via interactive media or videos, and share your work with your peers to critique and reflect the process of writing case notes. Good notes provide documentation the therapist is following acceptable standards of care, utilizing appropriate interventions, describing the results of these interventions and documenting the disposition of the case. The Law Review Staff believes one lends itself to the other. Include information to make it all flow together as a narrative. III. A look at what contributes to legible handwriting and some exercises to prevent cramp or tiredness. Do you hand-write case notes or other records? You may wish to refer to other law reviews for alternative organizations. Keeping notes is a way for the clinician to document their clinical assessment, interventions and result or follow-up. Having the right case management tools for your organization means streamlined processes … The following organization is a flexible guideline. Blue and black pens are the colours of preference for legal documents as they photocopy well and are easier to read. A good case management system for human and social services is more than just a place to store your notes. 2 Tips for Writing Better Consult Notes.