Tips on Writing Social Work Notes


Write On! Practical Suggestions for Preparing Social Work Records

by Katherine Dunlap, Ph.D., MSW

Social workers are people-oriented. They enjoy meeting new clients, helping folks master problems, and watching clients and colleagues grow toward their full potential. Often, social workers do not like recording this process in case notes. “Let me work with people,” my students frequently exclaim. “I want to make a difference, not write a novel!”

But the truth is that social workers often write documents that change people’s lives. Court reports, grant proposals, and even case records can make dramatic differences in the circumstances of those we serve. To be good social workers, we must master not only the art of helping clients, but also the skill of writing about them and the services we provide. This article presents six simple strategies to help you improve your writing—and maybe even your attitude toward it.

First, make a time and place.

In our direct practice classes, we talk passionately about how to arrange chairs for an interview and how to ensure confidentiality, but we rarely mention the physical setting that helps us produce our reports. At a minimum, a writer needs a desk, adequate lighting, and paper and pens or a computer. Most need a quiet atmosphere to concentrate.

A little time and a quiet haven may be treasured commodities in a busy agency. Interns are likely to share telephones, desks, and cubicles with a supervisor or other student workers, and the noise levels in these areas can be quite high. Under these conditions, it is easy to relegate writing to second, third, or even fourth place. To avoid getting behind on reports, you must take charge of your time and place for writing.

• Structure your space to accommodate your writing.
• Clear your desk; give yourself room to work.
• Schedule a definite time for preparing daily reports, and stick to your schedule!
• Finish documents before you leave the office.
• Trade phone time with a colleague to reduce interruptions.
• Ask others to support your effort by keeping noise levels down.

Now that you have your basic tools and the proper setting, it’s time to write! Here are a few more pointers to help you achieve success.

Second, assemble your tools.

Just as students need the DSM-5 to complete a diagnosis, they need the proper resources to compile a professional document. To improve your writing, you will need four types of references: a dictionary, a thesaurus, a style manual, and a book that reviews the various types of social work notes. Each of these serves a different function.

The dictionary enables you to check spelling, exact meaning, and common usage of a word. If you are dictating notes, you must spell proper names and unusual words so the typist can prepare an accurate document. If you use word processing to write your own notes, learn to use the “spell-check” feature. But don’t depend on this feature to correct all your errors; spelling checkers don’t know whether you meant “their” or “there,” for example.

The thesaurus helps you select the best word to describe a situation. For example, many words can express happiness: delighted, ecstatic, thrilled, glad, cheerful, merry. A thesaurus helps you paint a word picture that conveys your message with precision. Bartlett’s Roget’s Thesaurus (1996) is a standard reference book. Most word-processing programs now include an easy-to-use thesaurus.

A style manual is essential for research reports and papers while you are in school, and it will also be helpful after graduation. “This is my last paper,” I often hear students say. “Wrong!” I muse. You may think that you will never write another paper after graduation, but you will probably find that you want to share your experiences with stakeholders, colleagues, and consumers. You may be asked to prepare an annual report, contribute to a grant proposal, or summarize the findings of a pilot program. You may see the need for consumer-friendly brochures, program descriptions, and agency manuals; you may want to present your experiences at an annual conference or share your thoughts in a journal. A style manual can help you with each of these writing projects.

Several style manuals are available. The most commonly used by social work journals is the Publication Manual of the American Psychological Association, often called the APA Manual (1994). Others include the Chicago Manual of Style (1993) and Turabian’s classic text (1996). Before you buy a style manual, check to see if your school or employer has a preference.

The style manual shows the proper form for reference lists and bibliographies, and these are the sections you will use most often in school. But a style manual is much more than a guide for lists. It also provides information about typing, word usage, punctuation, and organization. For example, which is correct: “fifteen,” “15,” or “fifteen (15)”? How do you decide whether to use “farther” or “further”? Should you write “The Williams’ ” or “The Williamses”? Your style manual speaks to each of these and more.

In addition to these reference books, you will also need a book that describes different types of social work records. What is the difference between a process recording and a progress note? A psychosocial assessment and a social history? A SOAP note and a problem-oriented medical entry? A records manual specifies the form and content for each of these types of documentation. Recording by Wilson (1980) is a classic text that you are likely to see in your field instructor’s bookcase. A more current choice might be Social Work Records, which provides a history of record-keeping, presents standard forms and formats, and discusses current issues in the field (Kagle, 1996).

These books are not expensive, and you can often find used editions in college bookstores. Try to purchase one each semester—be sure to get the latest edition—and soon, your armamentarium will be fully stocked!

Third, avoid gender-specific language.

Cardinal social work values include respect for the dignity and worth of the individual and the uniqueness of each person (Hepworth, Rooney, & Larsen, 1997; Compton & Galaway, 1994). In writing, we can operationalize these values by using non-gender-specific language (Dumond, 1990). In other words, we avoid phrases like “mankind” and “man-made.” We eschew gender-specific words like “businessman,” “policeman,” and “congressman.” Equally offensive are feminized words like “actress” and “waitress.” Both your thesaurus and your style manual will suggest alternatives. For example, more accurate phrases such as “humankind” and “manufactured” can replace “mankind” and “man-made.” For “businessman,” “policeman,” and “congressman,” substitute “executive,” “police officer,” and “member of Congress.” Actor, server, and even waiter are accepted terms for both men and women in these roles. Finally, it is not necessary to state that a nurse is male or that a mechanic is female.

In professional writing, we don’t refer to all clients collectively as either male or female. The easiest way to avoid using a global “he or she” is to make all pronouns plural. This leads to the next pointer.

Fourth, ensure noun/pronoun agreement.

In recent years, many conscientious writers have worked hard to avoid gender-specific language only to fall into another, equally awkward trap involving noun-pronoun agreement. For example:

When a social worker writes a court report, they should proofread it carefully.

The subject of this sentence, “social worker,” is singular; but the pronoun, “they,” is plural. This sentence can be fixed by bringing the pronoun into agreement with the noun; however, this leads us back to using either a gender-specific pronoun or the awkward and tiresome “he or she.” A better solution is to make the noun plural. The sentence becomes:

When social workers write court reports, they should proofread them carefully.

Another solution is to rewrite the sentence and eliminate the pronoun entirely:

A social worker who writes a court report should proofread it carefully.

Fifth, practice proofreading.

Proofreading is an essential skill that can be learned. There are two methods of proofreading: by computer and the old-fashioned way—reading. Both techniques are valuable, and together, they help you create letter-perfect documents.

To proofread a computer-generated report, first use the spell-check feature. This device will catch commonly misspelled words. Second, use the grammar program to help you determine correct usage. Third, use word search to examine your particular challenges. For example, if you tend to have difficulty with noun/pronoun agreement, search for “their” and “they.” Does each use follow a plural noun? Once you find your errors, you can easily rewrite your sentences.

While computer programs are helpful, they are not sufficient by themselves. They cannot discriminate among synonyms; and they do not catch correctly spelled substitutions such as “is” for “it,” or “to” for “of.” Even the best grammar program cannot help you achieve logical organization or comprehensive coverage. To master these details, writers must also learn to proofread their documents personally.

Start by looking at each word in each sentence. Concentrate first on the words themselves. Are they spelled correctly? Does each word precisely capture the essence of your message? Have you avoided gender-specific language and problems with agreement?

Second, look at content. Did you begin at the beginning? Did you state all essential facts? Did you cover the “Five Ws”: who, what, when, where, and why? Did you include all essential elements for the type of report you are writing? Did you date and sign your note?

Third, have you organized your work so that it can be used easily by others? Each paragraph should have a beginning, middle, and end; and each report should contain the same elements. Categorical headings such as “client description,” “goals,” and “outcomes” help organize material, even if these are not included in the final version.

Sixth, write nothing more, nothing less.

Because social workers often write for other busy professionals, such as judges or physicians, our notes should concisely state pertinent facts without commenting on irrelevant issues. As E. B. White exhorts, “Omit needless words. Vigorous writing is concise” (1979, p. 23).

This dictum is also true in social work. Home health social workers need not address income or expenses unless financial concerns interfere with the patient’s recovery. Home health progress notes should be limited to the specific conditions for which social work services have been ordered. Similarly, school social workers should not speculate on family issues they have not been asked to address, and eligibility specialists do not usually explore intrapsychic issues.

Unnecessary verbiage also creates a barrier to communication. When we stray from the presenting problem, insert personal opinions, use pompous language, or ramble about superfluous details, the reader quickly loses interest, and the client loses out.

Here’s one for practice.

The following note was written by a social worker at a service agency. Does this note contain all the facts needed for a decision about services? Does it include any extraneous material? Try your hand at identifying and correcting the variety of typographical errors, inconsistencies, and examples of poor writing in the following paragraph:

Mrs. Smith is an 64-year-old female living in Public Housing with her daughter, granddaughter, adult son. Ms. Smith come to Emergency Services to request assistence to purchasing food for her family. She reports that she has been the primary wage earner for this household, but was recently laid of from her job as a waitress. Mrs. Smith states that she has no savings as she has use everything too send her son to school to become a male nurse. Mrs. Smith cried when she tole me that her granddaughter had to accept free lunch. When the previous social worker interviewed her, they said she was not elegible for our services. Needs help.

Access campus resources.

At least 16 corrections are needed in the sample paragraph above. If you had difficulty identifying them, you may want to access the resources on your campus. Colleges and universities offer specific classes designed to develop technical writing skills. In addition, many schools offer workshops dealing with organization, writing anxiety, and time management. Peer tutoring and writing groups offer exciting, enjoyable opportunities to reinforce newly acquired skills.

Take advantage of campus services now. When you join the ranks of professional social workers, you will be richly rewarded for the time you invest today in writing.


References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychological Association. (1994). Publication manual of the American Psychological Association. Washington, DC: Author.

Bartlett’s Roget’s Thesaurus. (1st ed.). (1996). Boston: Little, Brown, and Company.

Compton, B. R., & Galaway, B. (1994). Social work processes (5th ed.). Pacific Grove, CA: Brooks/Cole.

Dumond, V. (1990). The elements of nonsexist usage: A guide to inclusive spoken and written English. New York: Prentice Hall.

Hepworth, D. H., Rooney, R. H., & Larsen, J. A. (1997). Direct social work practice: Theory and skills (5th ed.). Pacific Grove, CA: Brooks/Cole.

Kagle, J. D. (1996). Social work records. Prospect Heights, IL: Waveland Press.

Turabian, K. L. (1996). A manual for writers of term papers, theses, and dissertations (Rev. by J. Grossman & A. Bennett). (6th ed.). Chicago: University of Chicago Press.

University of Chicago Press. (1993). The Chicago manual of style (14th ed.). Chicago: Author.

White, E. B. (1979). Elements of style (3rd ed.). New York: MacMillan.

Wilson, S. J. (1980). Recording: Guidelines for social workers. New York: MacMillan.

Katherine M. Dunlap, Ph.D., MSW, is Director of the Charlotte MSW Program of the University of North Carolina at Chapel Hill. She wishes to thank Dr. Samuel D. Watson, Jr., University Writing Programs, UNC Charlotte, and Dr. Rachel Dedmon, School of Social Work, University of North Carolina at Chapel Hill, for reviewing earlier versions of the manuscript.

Copyright © 1997 White Hat Communications. All rights reserved. From THE NEW SOCIAL WORKER, Fall 1997, Vol. 4, No. 4. For reprints of this or other articles from THE NEW SOCIAL WORKER (or for permission to reprint), contact Linda Grobman, publisher/editor, at P.O. Box 5390, Harrisburg, PA 17110-0390, or at linda.grobman@paonline.com, or at (717) 238-3787 (phone/fax).