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SSE 205 - Case Report Writing and Documentation

1. Identify key elements of effective case report writing in order to be able to properly document a client’s history, treatment goals, progress, critical incidents, and referrals, including legal and ethical issues regarding client confidentiality, informed consent and access to records. (Council on Social Work Education [CSWE] Competency 1)
2. Create written case records including an intake assessment, treatment plan, progress note, critical incident report, and a referral letter for a client (CSWE, 1, 7 and 8).
3. Practice effective internal and external agency communication advocating for the needs of clients.  (CSWE Competencies 1, 2, 3 and 5)
4. Evaluate key aspects of a client case report to identify strengths and weaknesses and elicit constructive peer feedback.  (CSWE Competency 1 and 9)

1. Apply basic principles of documentation.
2. Complete intake forms, progress notes, treatment and crisis plans, referral letters, court statements and child and family team reports.
3. Write case summaries and release of information documents.
4. Utilize the Health Insurance Portability and Accountability Act (HIPPA) basics in social services agencies.
5. Write a professional case report including reason, identifying data, audience, history and summary.
6. Analyze the ethical, legal and liability issues related to managing client’s information and report writing.
7. Describe procedures and technology used by social services agencies to protect client’s data.
8. Understand the importance of cultural competence.
9. Explain the importance of confidentiality and identify occasions when confidentiality cannot be kept.
10. Explain common liability and malpractice issues.

1. Case Report Writing Elements
   1. Intake assessments
   2. Treatment plans
   3. Progress notes
   4. Crisis plans
   5. Referral letters
   6. Professional correspondence
2. Case Report Writing Considerations
   1. Technology
   2. Terminology
   3. Style
   4. Voice
   5. Grammar and common report writing errors
   6. Strengths or asset-based approaches
   7. Frequently used formats
      1. SOAP (Subjective Objective Assessment Plan)
      2. Core
      3. APA (American Psychological Association)
3. Case Report Content
   1. Types of reports
   2. Purpose and reason
   3. Audience
   4. History
   5. Strengths approach
   6. Summary
4. Ethical and Legal Issues
   1. Health Insurance Portability and Accountability Act (HIPPA) in social services
   2. Privacy
   3. Libel
   4. Confidentiality
   5. Client’s rights
   6. Malpractice issues
5. Current Trends in Behavioral Health Case Report Writing
6. Cultural Competence

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