Telling the Story in Case Notes
There is a saying in case note lore: "If it's not documented, it didn't happen." However, including each and everything in a case note is not what that means. Let's look at some of the best ways to make your case notes more valuable to the reader.
Case notes shouldn't be kept a secret. They need to tell a story that any reader can appreciate. Defined, case notes are records of the interaction with or progress of a customer/client. They can cover success or failure and may include:
- Documentation.
- Service strategies.
- Recount of conversations or appointments.
- Requested follow-up by customer or partners.
Basically, we are trying to tell the reader what is going on with that customer at that time without them having to ask you for follow-up information.
- Do:
- Use professional language as well as correct capitalization and punctuation.
- Address the situation with relevant details.
- Base notes on FACT (Observations are facts).
- Avoid bias by leaving out opinions and assumptions.
- Spell out acronyms before using them.
- Say what you mean directly.
- Don’t:
- Use slang, street language, clichés, or jargon.
- Use metaphors or similes.
- Write in a style that readers can’t easily understand.
- Write about personal details that don’t affect the case.
- Include personally identifiable information (PII).
Remember that case notes can be used in legal proceedings, so it is important to complete them properly. Make sure that any case notes you write can hold up in a court of law.
Several other things should be considered when writing a case note. Case notes should be:
- Clear – Often, we are too close to what we are writing. We understand what we just said, but will any reader be able to understand it. If you are unsure, ask someone to read your case note to see if it makes sense to that person.
- Concise – This might be considered subjective, but we mean to ensure that all relevant information included is in as brief of a format as possible.
- Useful – People who grew up watching Dragnet may remember the term "Just the facts ma'am". The phrase from the show is actually "All we want (or “know”) are the facts, ma’am". This is the basis of useful case notes. They are the facts as we know them or have been told. To keep them useful, remember to include the 5 W's plus How and Next Steps. Read below to find out more.
- Relevant – This might be synonymous with useful. If something is mentioned in passing, it should not be recorded in a case note unless it is relevant to the situation at hand.
- Timely – Case notes should be written quickly or within a reasonable amount of time after the activity that took place with the customer.
- Identifiable – If the system that you are using does not automatically track who the writer is and when the case note was written, you will need to ensure that the text of the case note includes this information. If it is automatic, many people will begin a case note with "This writer..."
Be aware of your audience. Are you writing for the customer, a co-worker, your supervisors or administrators, partner organizations, funders, or monitors? Tell a story in your case notes that gives a reader all it needs to know to determine its intent.
The authoritative body may dictate how frequently you write a case note.
- A daily case note may recount a quick interaction like a phone call, text, or reference to an emergency.
- Weekly case notes may provide a recap of activities or communication where the level of intensity may have precluded daily case notes.
- Monthly case notes are probably the most likely time frame of all. They are used to recount a customer's progress since the last reporting period.
- Quarterly, initial, and completion are other time frames that may require a case note recap.
Writing a case note is like writing a press release. When sending a press release out for pick-up by an agency, it is unknown who the reader will be. Using “5W1H analysis” when writing – who, what, where, when, why, and how – is essential. For case notes, the only real addition is adding next steps. Watch our webinar recording to find some great examples of what and what not to write to make the perfect case note.
Some case note systems allow you to select the type of note you are going to write. The rubric we prepared provides a way for you to know what to include to:
- Meet the standards for a good case note.
- Things to include to exceed standards.
- What you should avoid including that will take the case note below standard.
Remember that case notes are legal representations of the customer’s case. The PowerPoint presentation includes a list of words that are useful in case notes and a list of words that should be avoided.
Great case notes come from telling the whole story, sharing the facts, and knowing that anyone can pick up where you left off.
Case Note Writing Rubric