Documentation Basics
To provide a legal, ethical, and clinical record of client services.
What is the purpose of professional documentation in social work?
Clear, objective, respectful, and free from bias.
Define the “professional voice” in social work writing.
HIPAA
What federal law protects client records?
SOAP
Subjective, Objective, Assessment, Plan.
Consult agency policy and supervisor/legal counsel.
What is you receive a subpoena for client records. What do you do first?
Accurate, timely, objective.
Name three qualities of effective documentation.
Client appeared visibly distressed and tearful.
Rewrite: “Client was super upset.”n Many answers accepted.
When legally mandated (e.g., court order, duty to warn).
When can you release client notes without consent?
Clinician’s interpretation or clinical impression.
What belongs in the “Assessment” section?
Briefly note precipitating event, immediate interventions, and outcome.
How would you document a crisis session?
Date, time, client name/ID, and session type.
What should always be included in the opening of a client note?
“Person with substance use disorder,” not “addict.”
Give an example of person-first language.
Only sharing information essential for the purpose of communication.
What is “minimum necessary disclosure”?
DAP combines Data, Assessment, and Plan — no separate “Subjective/Objective.”
What is the main difference between SOAP and DAP notes?
Risk assessment, protective factors, safety plan, and consultation.
A client discloses suicidal ideation. What must be documented?
A note written after the service occurred; label as “Late Entry” with original service date.
What is “late entry” documentation, and how should it be labeled?
Avoid blame, validate resilience, and describe behaviors without judgment.
How do you maintain a trauma-informed tone in documentation?
NASW Code of Ethics 3.04 (Client Records).
What ethical standard governs social work record-keeping?
Client will attend next session on 11/10 to review coping plan.
Write one concise “Plan” entry.
Timeliness, completeness, and adherence to policy.
Your note is reviewed during an audit. What demonstrates compliance?
Ethical violation and compromised client care.
Identify two risks of incomplete documentation.
Subjective: client’s reported experience; Objective: observable facts.
What is the difference between subjective and objective writing.
Strike through with a single line, note “error,” initial, and date.
How do you handle documentation errors?
Personal opinions or speculation unrelated to treatment.
Identify an example of inappropriate content for a clinical note.
Client missed 3 consecutive sessions; motivation for treatment will be reassessed.
Document this ethically: “Client missed 3 sessions and probably doesn’t care about therapy.”