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
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.