Guidelines for Social Work Case Management Documentation

What does the NASW Code of Ethics Say?

3.04 Client Records
a.

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.

General Professional Guidelines

Consider case management record to be a legal and/or medical document

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.

Do not leave blanks; write N/A (or not applicable)

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)

Tips and Suggestions

Highlight the clients strengths, supports and coping mechanisms

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,)

Remember to report negative (absent) as well as positive (present) observations/information/findings

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

Never use your own or casual abbreviations (use medical abbreviations)

Do not take shortcuts at the cost of clarity

Do not use generalizations or over-interpretations

SPELL CHECK!...this is your integrity!

Do not use jargon

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)

Do not make recommendations without backing of facts and reason

Initial Intake or Assessment Note

o

Completed documentation within 48 hours of meeting and supporting documentation should be included within 30
days (i.e proof of income).

Includes introduction of social work case manager/program role and purpose

Includes client rights and responsibilities and grievance mechanism

Client should receive a copy of any work completed together and signed

Includes, but is not limited to:

referral reasons/process

behavioral observations

current living situation

family history

support system

education/employment

financial/insurance

mental health/substance abuse

medications/medical concerns

coping behaviors

legal issues

advance directives

client/family goals

clinical assessment

psychosocial concerns/problem identification

violence/suicidality history

spiritual/cultural factors

Goal Planning/Care Plan

o

Both short and long term goals/care plan documented

Signature of both client and social work case manager

Priorities and consequences of achievement/non-achievement

Achievements toward or changes in goals documented

Signature (or other documentation of commitment of client and worker)

Progress Notes

Always dated by contact/intervention (If writing late state late entry. If adding information state addendum to note dated
XX/XX/XXXX)

Document type or place of contact using:

Home visit, face-to-face, clinic/agency visit, hospital, telephone, mail, collateral contact, community
contact, etc.

Document outcome of contact using:

Missed by client, missed by CM, DNKA (did not keep appointment), completed, rescheduled, etc.

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...)

Sign using credentials (e.g. Sally Social-worker, MSW)

Common Documentation Acronyms, Abbreviations and Statements

WHAT DOES IT MEAN?

NOTES ON USAGE

/c

With

/s or w/o

Without

ADLs or
Activities of
Daily Living

Can this person care for

him/herself and how well
accomplished are the daily
tasks?

The client states that

these medication side
effects do not affect
his ADLs.

AMA

Against Medical Advice

Do not use unless the

source is a medical
professional

CC

Chief Complaint OR
Courtesy Copy

Clt or ct

Client

CM or SW

Case Manager or Social

worker

Compliance or Refers to clients

Adherence
participation in an
intervention or treatment

Client is not adherent

to medication or
medical care as
prescribed

d/c

Discontinued

Usually used with

medications

D/ch

Discharged

D/O

disorder

DNKA

Did not keep appointment

DOB/DOD

Date of Birth/Date of Death

Dx

Diagnosis

ETOH

Alcohol

Hx or h/o

History or history of

IDU,
intravenous
drug use

Use of needles to administer

drugs intravenously

Usually used in
substance abuse or
HIV risk assessment

IEP

Individual education plan

Used in schools

LD

Learning disabled

Use only if backed by

assessment

LEP

Limited English Proficiency

MDT

Multidisciplinary team

Medication
Regimens

q.d. = everyday o.m. = every morning b.i.d. = twice

a day
t.i.d. = three times a day q.i.d. = four times a day
p.c. = with meals p.r.n. = as needed p.o. = by

mouth/oral
h.s. = at bedtime i.v. = intravenous

MH

Mental health

MSE

Mental Status
Exam/Evaluation

MSM

Men who have Sex with

Men

Rather than labeling

as gay orhomosexual,
this term refers to the
behavior

NOS

Not Otherwise Specified

Usually used in
mental health
evaluation or
diagnosis

PLWH or
PLWA

Person Living With HIV/

AIDS

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

Socially and emotionally

maladjusted/disturbed

SMR/PMR

Severely/profoundly
mentally retarded

SPMI

Severe and Persistent Mental

Illness

SSN

Social Security Number

Sx

Symptom

w/d

Withdrawal

~~~~ SAMPLE PROGRESS NOTE ~~~~~

Bob Smith # 9998989

Confidential Progress
Notes

ABC Case Manager Miracle Worker

Date

Contact Notes

06/04/03 CC

CM received a call from the intake coordinator who

stated that ct was in need of housing and mental health
counseling. Intake coordinator set appointment for
06/05/03. CM will contact ct to confirm appointment (ct
gave permission for referral and phone
contact).-----------------------------Miracle Worker,
BSW

06/05/03 AV

Ct arrived for appointment 45 minutes late. Ct stated

that he did not have transportation and had to walk to
the agency. Ct is a 45 year old Error MW 35 year old
Caucasian man. Ct was dressed appropriately for the
weather (warm, wore light clothing). Ct was talkative,
volunteered feelings/information freely and initiated

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 Client Record Page _1_ of _2_

T= telephone, HV = Home Visit, AV = Agency Visit, M= Mail, CC = Collateral Contact, O _____ = Other

Bob Smith # 9998989

Confidential Progress
Notes

ABC Case Manager Miracle Worker

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

Confidential Client Record Page _2_ of _2_

T= telephone, HV = Home Visit, AV = Agency Visit, M= Mail, CC = Collateral Contact, O _____ = Other