- 1). Include identifying information that your company requires you to write on case notes. This information usually includes patient's name, medical record number, date of service and time of service. Depending on your company, you may be required to include other information.
- 2). Explain the service you performed in the first paragraph of your case note. State that this was the initial interview with the patient face to face. Be sure to include a statement if the patient you saw was accompanied by a family member or friend.
- 3). Describe your impressions of the client including his mood, his affect, whether he was orientated and his hygiene. Include relevant details that the patient or his family said to you, adding quotes whenever possible. This section will be longer in your initial interview because of the amount of information you received. Keep in mind that anything you write is part of a legal record. Do not give opinions or judgment.
- 4). Note any measurable goals in the next paragraph. You will need to show outcomes in future case notes for managed care and your supervisor. Establish goals with your client and document them in the note. For instance, in a hospital setting the goals could be related to physical improvements which are easily measured.
- 5). Provide a clear summary of the intervention that you used during the session, such as cognitive behavioral techniques or mediation. Managed care and insurance companies read over clinical notes to ensure that you are using effective strategies when working with clients.
- 6). Document your clinical impressions of your client and treatment plan. State prognosis and estimated treatment time and frequency of sessions. Include any homework that you may have assigned your client. Assign a Global Assessment of Functioning (GAF) score if required.
- 7). Sign your note and file in client's chart. The note not only provides information to other professionals but serves as a record of your service. It is important that it is filed in case of an audit.
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