Guidelines for Social Work Case Management Documentation
SW 611 ~ Guidelines for Social Work Case Management Documentation
What does the NASW Code of Ethics Say?
3.04 Client Records
  1. Social workers should take reasonable steps to ensure that documentation in records is accurate and reflects the services provided.
  2. Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future.
  3. Social workers' documentation should protect clients' privacy to the extent that is possible and appropriate and should include only information that is directly relevant to the delivery of services.
  4. Social workers should store records following the termination of services to ensure reasonable future access. Records should be maintained for the number of years required by state statutes or relevant contracts.

General Professional Guidelines

Tips and Suggestions

What to avoid

SW 611 ~ Guidelines for Social Work Case Management Documentation

Initial Intake or Assessment Note

Goal Planning/Care Plan

Progress Notes

Home visit, face-to-face, clinic/agency visit, hospital, telephone, mail, collateral contact, community contact, etc.

Missed by client, missed by CM, DNKA (did not keep appointment), completed, rescheduled, etc.

 

 

 
SW 611 ~ Guidelines for Social Work Case Management Documentation

Common Documentation Acronyms, Abbreviations and Statements

 

WHAT DOES IT MEAN?

NOTES ON USAGE

/c

With

 

/s or w/o

Without

 

ADLs or Activities of Daily Living

Can this person care for him/herself and how well accomplished are the daily tasks?

The client states that these medication side effects do not affect his ADLs.

AMA

Against Medical Advice

Do not use unless the source is a medical professional

CC

Chief Complaint OR Courtesy Copy

 

Clt or ct

Client

 

CM or SW

Case Manager or Social worker

 

Compliance or Adherence

Refers to client’s participation in an intervention or treatment

Client is not adherent to medication or medical care as prescribed

d/c

Discontinued

Usually used with medications

D/ch

Discharged

 

D/O

disorder

 

DNKA

Did not keep appointment

 

DOB/DOD

Date of Birth/Date of Death

 

Dx

Diagnosis

 

ETOH

Alcohol

 

Hx or h/o

History or history of

 

IDU, intravenous drug use

Use of needles to administer drugs intravenously

Usually used in substance abuse or HIV risk assessment

IEP

Individual education plan

Used in schools

LD

Learning disabled

Use only if backed by assessment

LEP

Limited English Proficiency

 

MDT

Multidisciplinary team

 

Medication Regimens

q.d. = everyday o.m. = every morning b.i.d. = twice a day

t.i.d. = three times a day q.i.d. = four times a day

p.c. = with meals p.r.n. = as needed p.o. = by mouth/oral

h.s. = at bedtime i.v. = intravenous

MH

Mental health

 

MSE

Mental Status Exam/Evaluation

 

MSM

Men who have Sex with Men

Rather than labeling as gay or homosexual, this term refers to the behavior

NOS

Not Otherwise Specified

Usually used in mental health evaluation or diagnosis

PLWH or PLWA

Person Living With HIV/ AIDS

Usually used in advocacy work

PRN

As needed

Uusually referring to medical care

R/O

Rule Out

Usually referring to DSM-IV diagnosis

Rx or Tx

Treatment or Therapy

 

SEM/SED

Socially and emotionally maladjusted/disturbed

 

SMR/PMR

Severely/profoundly mentally retarded

 

SPMI

Severe and Persistent Mental Illness

 

SSN

Social Security Number

 

Sx

Symptom

 

w/d

Withdrawal

 

 

 
SW 611 ~ Guidelines for Social Work Case Management Documentation

~~~~ SAMPLE PROGRESS NOTE ~~~~~

Bob Smith # 9998989

Confidential Progress Notes

ABC Case Manager – Miracle Worker

Date

Contact

Notes

06/04/03

CC

CM received a call from the intake coordinator who stated that ct was in need of housing and mental health counseling. Intake coordinator set appointment for 06/05/03. CM will contact ct to confirm appointment (ct gave permission for referral and phone contact).-----------------------------

--------------------------------------------------------Miracle Worker, BSW

06/05/03

AV

Ct arrived for appointment 45 minutes late. Ct stated that he did not have transportation and had to walk to the agency. Ct is a 45 year old Error MW 35 year old Caucasian man. Ct was dressed appropriately for the weather (warm, wore light clothing). Ct was talkative, volunteered feelings/information freely and initiated conversation comfortably.

During initial assessment, ct was unclear on the reason for referral and stated that his doctor told him that he needed CM services (Dr. John Smith with XYZ medical center – see referral form). Cm and ct discussed ct-defined problems, formed descriptive problems statements and completed strengths assessment (see assessment form). Ct was uncomfortable with identifying own strengths and supports. CM assisted with education about Strengths Perspective style of Case Management and the role and purpose of the services offered by ABC agency. Ct agreed that he wanted to access services (concurrent with doctor referral).

Ct described his history of homelessness since childhood and survival skills used. Ct stated that he prefers not to access homeless shelters and his experiences with such housing services included having belongings stolen and or defaced. Ct indicates that he often lives temporarily with friends and acquaintances that he has met on the street and at shelters. Ct is often expected to pay for this temporary housing through food, alcohol or illegal drugs (marijuana and crack). Ct does not have a regular employment or paycheck from work error MW-- income source but has worked for temporary labor agencies and has done work for cash. Ct stated that when he is lacking on resources he knows how to find income source (usually limited, not reported, and include both legal/illegal work). Ct denied substance abuse concerns, but uses some sort of drug at least 3x per week. Ct stated that substance use does not affect with ADLs however has been denied medical appointments at least 4 times due to being drunk or high. Ct has also been asked to leave formal temporary housing programs due to substance use. Ct feels that this is unfair and was not able to access needed medical care or formal housing programs.

Confidential Client Record Page _1_ of _2_

T= telephone, HV = Home Visit, AV = Agency Visit, M= Mail, CC = Collateral Contact, O _____ = Other

Bob Smith # 9998989

Confidential Progress Notes

ABC Case Manager – Miracle Worker

Date

Contact

Notes

Continued from 06/05/04

 

Continued ---------------------------------------------------------------------------

Ct denies any legal problems related to substance use or other activity. Ct described limited contact to family and asked to avoid any discussion on exploring family relations as informal supports or as a resource for support or housing........................more description of assessment appointment, client needs, deficits in resources, strengths, formal and informal supports and needs................................................................

See Goal Planning worksheet completed by both ct and CM at this appointment. Ct will indicated interest in Shelter Plus Care housing program, but did not want to commit today. ------------------------------

PLAN: Cm and Ct will work on application next appointment. Ct has two medical appointments scheduled and has committed to abstaining from alcohol/drug use before each appointment. Ct and CM strategized that this is more realistic for morning appointments; CM will assist in rescheduling 6/14/04 appointment for a morning time slot. Ct agreed to contact Cm next Tuesday (06/08/04) to discuss eligibility for other support programs offered by ABC including the men’s luncheon support program for homeless men. Ct indicated no other concerns or expectations at this time, but agreed to further conversations about goal planning at next meeting. CM will fax applications completed today including bus pass and lunch pass applications. .......................................................................Miracle Worker, BSW

06/09/04

No Contact

Ct did not contact CM as agreed upon in last meeting (agreed for 06/08/04). CM sent letter to temporary address left by ct. reminding him of medical appointment that was rescheduled on 06/14/04 (see letter copy in chart)---------------------------------------------- Miracle Worker, BSW

     
     
     
     
     
     
     
     
     
     
     

Confidential Client Record Page _2_ of _2_

T= telephone, HV = Home Visit, AV = Agency Visit, M= Mail, CC = Collateral Contact, O _____ = Other

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