by: susana estanislao writing case notes “documenting what has transpired during the therapeutic...

By: Susana Estanislao

WRITING CASE NOTES

“Documenting what has transpired during the therapeutic session”

What?

Why?

How?

We are expected to accurately document

what transpired during the therapeutic hour (Cameron and Turtle-Song, 2002)

Being able to explain what practitioners are doing in counseling because of existing records may connote quality of services rendered.

Good documentation is a fundamental part in providing minimal care, and needs to be mastered like any other counseling skill.

What?

PROGRESS NOTES

CASE NOTES

- Part of the student records kept in the guidance and counseling office to ensure the recording of annotations, anecdotal, test results, comments, observations and proceeding which occurred during the counseling session or therapeutic hour.

CASE NOTES

- These are written documents maintained inside the individual student folder, which

are secured for the purpose of confidentiality.

Why?

1. It serves as record for other counselors who may meet with the same client being handled in an emergency or when the client transacts to another counselor.

2. For supervision and court purposes

3. For easy recall and reference purposes

4. Conceptualization of client’s problem is better facilitated and treatment plan is efficiently formulated.

Cameron and Turtle-Song, 2002

(Subjective, Objective, Assessment, Plan)

SOAP

Problem-Oriented Medical Records(POMR)

Problem-Oriented Medical Records

(POMR)

4 dimensions

CLINICAL ASSESSMENT

Focuses on information gathered during the intake interview sessions.

This component includes: the reason/s why the client is seeking treatment, secondary complaints considering the client’s personal, family and social histories, psychological tests, if any, diagnosis and recommendation for treatment.

PROBLEM LIST

Includes an index of all problems, active or inactive, derived from the client’s history.

TREATMENT PLAN

Is a statement of the possible therapeutic strategies and interventions to be used in dealing with each noted problem. These plans are stated as goals or objectives, which are written in behavioral terms in order to track the client’s therapeutic progress, or lack thereof. 

PROGRESS (CASE) NOTES

Are generally written using the SOAP format and served to bridge the gap between the onset of counseling services and the final session.

CONTENT

SUBJECTIVE: Client’s reason for coming, presenting problem/ concern, reason for referral, what client talks about: what the pertinent others tell about the client; how the client experiences the world.

PROCESS

OBJECTIVE: Factual: Client’s non-verbal behaviors/ verbal statements/ feeling tone, what the counselor personally observed/ witnessed. Quantifiable – what was seen, counted, smelled, heard or measured. Outside written materials received.

CASE CONCEPTUALIZATION

ASSESSMENT: Client’s underlying problem/s, concerns, predisposing risk factors, perpetuating factors and precipitating causes affecting or contributing to the problem/s – summarized clinical diagnosis and impressions; synthesis and analysis of the subjective and objective data; counselor’s clinical thinking and reflections.

INTERVENTIONS

PLAN: Action Plan – counselor’s techniques, interventions, treatment progress and direction, date of next appointment. Prognosis – anticipated client’s gains from the interventions – poor, fair, good.

CASE NOTES FORM

Client Name: ______________ Gender: __ Age: __ Status: ___Level/ course: _____________ Institution: ________________Date: ____________________ Session no. and length: ________

•CONTENT: SUBJECTIVE

•PROCESS : OBJECTIVE:

•CASE CONCEPTUALIZATION: ASSESSMENT

•INTERVENTION: PLAN

Counselor’s Signature over Name

Thank You