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

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

SOAP Notes

  • Subjective
  • Objective
  • Assessment
  • Plan

Learning to Write Case Notes using the SOAP Format

Here is another resource...though it is focused on medical documentation..for SOAP notes

Tips on Writing Social Work Notes

MaineCare Language Guide


Assessment

Lesson 16 Assignment

For this assignment find a person willing to play the role of a client and conduct a basic counseling session about "how things are going" in that person's life. Then compose a SOAP note that clearly identifies what happened in the session.