Lesson 16: Documentation
Attention
Learning Outcomes
Upon completion of this lesson's material, students will be able to:
- Demonstrate how to document client interactions
Teaching
Read Chapter 24
It is important to accurately document all contact with clients and service providers when collaborating on a case. All documentation becomes a legal document which means it can be used in court or for any other legal purposes. It is important to know how to document your interactions appropriately.
It can be said..."if you did not document it, it did not happen"
Who is invested in being able to access documentation?
- The client
- Yourself
- Your supervisor
- Clinicial Supervisor
- Insurance
- Licensing
- Legal Services
SOAL Notes
- Subjective
- Objective
- Assessment
- Plan
Learning to Write Case Notes using the SOAP Format
Tips on Writing Social Work Notes
Assessment
Lesson 16 Assignment