While most case managers know that proper documentation is crucial for maintaining ethical standards and program compliance, it can often feel burdensome and overwhelming. Case managers experiencing this overwhelm may look for ways to make paperwork more efficient and meaningful. This blog post explores ways to streamline processes so that documentation supports, rather than hinders, the compassionate care case managers provide to clients each day.
Write it down—or it didn’t happen.
As the adage goes, if you didn’t document it, then it didn’t happen. Case notes provide crucial information about meetings, progress, barriers, and next steps. Documentation also ensures continuity of care when another provider needs to cover a case, and it enables supervisors to provide effective guidance and oversight. If your agency undergoes an audit or is asked to supply information about certain programs or clients, a written record exists. This is especially important if there is a dispute with a client over whether or how services were rendered. In emergency or crisis situations, case notes can be vital to protecting the service provider and agency from liability.
As a service provider, documenting how much (and how hard) you are working with a client is also important if you need to advocate for yourself, whether you’re asking to reduce your case load or applying for a promotion with your supervisor. Additionally, documenting the quality and quantity of client interactions demonstrates your program’s outcomes when reporting to funders, which can help your agency to apply or reapply for future funding opportunities.
Creating a record of interactions and progress is equally important for clients as it is for you and your agency. Clients sometimes need evidence they have been meeting with a case manager or working toward specific goals to qualify for other programs or benefits. Or, if a client needs to transfer to a different agency or case manager, a record of their case and progress is ready to accompany them.
Keep it concise to save time and protect the clients.
Writing too many details in case notes can make them difficult to quickly review. It may take more mental effort to write a concise entry than a jumble of notes, but it’s worth it. Succinct paperwork is easier to review in preparation for future meetings, or to share with the client or other service providers, as needed and when appropriate. Paperwork should provide a comprehensive log of interactions with clients and include who was present, what happened, and when, where, and why the meeting occurred. If a case manager has multiple interactions with a client in one day in different program areas, a best practice is to write separate (concise) case notes to accurately record and organize data on the different services your clients is receiving. The clearer and more concise your paperwork, including those basics, the easier writing notes becomes over time, creating more efficiency in the long run.
There are also ethical considerations relating to how much detail to include in your documentation. Recording too many details or including your subjective opinions can jeopardize a client’s confidentiality if the case record needs to be shared (pending the client’s consent) with another service provider (or by legal mandate under subpoena). A good rule of thumb is to consider how the client would feel if they read the note.
Guidance on Writing Case Notes
For more guidance on what to include in your paperwork, including case notes, service plans, specialized documentation, and termination summaries, consult Switchboard’s guide on Creating High-Quality Case Management Documentation.
Use paperwork as an opportunity to center the clients and recognize their strengths.
Creating clear notes that include the client’s perspective, strengths, and priorities allows both case manager and client to continue in a productive collaboration toward the client’s goals and well-being—centering the client while maintaining compliance.
When working with a family or a case with multiple clients, it is important to take time to write down each individual’s goals and priorities independently, for both children and adults. This allows you to equitably serve all clients and keep their perspectives and specific needs in mind as you develop and carry out a plan for an individual case or family as a unit.
Clients may ask, “Why are you writing so much?” or, “Why are you writing down what I said?” It can be helpful to explain the importance of remembering their requests in their own words and accurately reflecting their wishes. It also helps build trust with your client to explain you are writing down your to-do tasks to show your accountability to their case. If a client is fearful of the extent of your notetaking, you can remind them of the confidentiality of the case file and that it helps you follow up effectively, though of course it does not guarantee you will be able to meet all of their requests.
Review Documents Ahead of Time
If you are starting to use a new form or template at work, take time to review it before your first use in a client meeting. Ask yourself:
- Why are the different components of the form important?
- How can I use this form to capture the most crucial information and details from a client interaction?
- How will what I write become useful in supporting the client’s progress?
Integrate the paperwork into your workflow.
The sooner you write your documentation, the easier it will be—and the more confidence you will have in the accuracy of your notes when you return to them later. Rather than trying to chase down your memories to catch up on case notes, commit to taking 10 minutes at the end of a meeting or interaction to jot down the highlights. At a minimum, you can keep a running list of client meetings you conducted throughout the day, to ensure you do not forget any interaction when you have time to case note. Another possibility is to email yourself a summary of your activity in the field (ensuring your email server is private and secure) to input formally back in the office. Interns or volunteers can also send this kind of secure email to case managers who are creating case notes on their behalf.
Make your own rule of thumb for when you will finish your documentation, and schedule it into your day (e.g., end of day for same-day notes, or no more than 48 hours later—something that seems realistic to you). One way to ensure you have time for paperwork is to schedule client meetings to be 45 or 50 minutes long—rather than a full hour—to give you time to write your notes at the end (and take needed stretch and restroom breaks). You could also block off the last hour of your workday to complete all outstanding paperwork. Make sure to check with your supervisor about agency expectations for completing case notes or blocking off time for documentation.
Try different notetaking styles.
Whether your agency keeps digital or handwritten documentation may affect your own note-taking practices. Consider your own ability and preference to fulfill your documentation requirement, ensuring that you keep your work laptop and any notebooks secure and confidential. Do you prefer to bring your work laptop with you to record notes during home visits, or would you rather write handwritten notes, dedicating time at the end of each day to transfer them into your agency’s digital system? Another option is to designate time after each client interaction to type complete digital case notes.
If you dislike or are uncomfortable with typing or writing by hand, you can try voice dictation of your notes. Make sure any dictation software you use has appropriate client confidentiality safeguards and is approved by your agency.
Consider adopting a case note template like this sample from Switchboard to streamline the process. If you have a template that you are comfortable with and is approved by your program and/or agency, you will spend less time trying to remember the necessary elements of a case note, enabling you to focus on retaining the important details of the meeting. Case managers can print a few copies of the approved case note template to keep on hand in the field.
All documentation that is recorded outside of the secure office environment should be protected by the agency’s Personal Identifying Information (PII) policies.
Conclusion
In short, the key considerations to keep in mind when writing high-quality case notes and documentation are as follows:
- Focus on concise, quality notes—overdocumentation obscures key details.
- Remain objective, avoiding opinions, judgments, and reactions.
- Incorporate the client’s perspective, remembering they are the center of this work and of our documentation.
- Block off administrative time to finish the documentation when possible.
- Use templates for consistency and efficiency.
Resources
The following resources from Switchboard offer additional information on how to improve case management documentation:
- Tool: Case Note Template (2023)
- Guide: Creating High-Quality Case Management Documentation (2023)
- Archived webinar: Creating High-Quality Case Management Documentation (2023)
- Archived webinar: Creating Balance in Case Management (2023)
