Social Work Progress Notes

Also referred to as case notes, social work progress notes are written records of clinical information and interactions with a client that are captured and presented in chronological order. 

Social work progress notes serve many purposes.  

Not only do they play an important role in client care, progress notes for social workers can also help streamline the administrative burden of clinical documentation. They can remind us where we left off during our last meeting with a client and what to focus on in our next session.  

With client consent, these documents can be sent to other providers to increase the effectiveness of continuity of care.  

Wondering how to write social work progress notes?  For those who accept insurance, progress notes for social workers are essential to justifying reimbursement, so it’s important to spend time writing clear and effective social work progress notes.

Types of social work progress notes

There isn’t one master note template that all social workers subscribe to. Various note templates can be useful tools for increasing the ease and consistency of documentation.  

When choosing your progress notes format, consider the needs of your clients, your clinical specialties, the clinical settings you provide care in, and the details you’ll need to include in documentation.  

Common formats of progress notes for mental health. include BIRP notes, SOAP notes, and DAP notes. Follow the hyperlinks in the previous sentence to see progress notes examples in the three most common formats.

Each note template has a slightly different focus, while also making sure objective data, intervention methods, and follow-up treatment plans are documented.

Here are some.

BIRP notes 

Behavior Issues and complaints the client demonstrated during the session, including emotional and behavioral observations.

Intervention: Intervention actions that were used to address the concerns.

Response: Client’s response to interventions. Did they assist in the alleviation of problem areas?

Plan: Follow-up actions or treatment focus for future sessions.

SOAP notes

Subjective: Client’s description of their issues or problem areas.

Objective: Social worker’s observed quantifiable and measurable data.

Assessment: Evidence-based conclusions of social worker’s observations.

Plan: Next steps to address issues.

DAP notes

Data: Reason for the visit, client’s mental status, changes since the last session, and interventions used.

Assessment: How the client responded to interventions, progress made, and any changes to treatment goals.

Plan: Any additional steps the social worker or client is expected to take.

Essential elements of social work progress notes

Whether you decide to go with one of the note templates above or create one of your own, there are certain pieces of information that you should always gather.  

One way to remind yourself of these elements is to ask yourself the following questions:

Who?

• Provider’s name and credentials
• Client’s name and date of birth (DOB)

When?

• Date of service
• Length of service
• Time of day

Where?

• Geographical location where service was provided (city, state, country of client and clinician)
• Clinical setting where service was provided (school, client’s home, office, virtually)

What?

• Client complaints or issues that were the focus of the session
• The interventions and skills you utilized to address issues

Why?

• Connect how issues are addressed and interventions are used to assist in overall goals and objectives for the client

What’s next?

• Next scheduled session date and time
• Homework client is expected to complete before the next session
• Referrals to other providers

Best practices for social work notes

Here are some best practices to keep in mind when writing social work progress notes.

Be objective

As mental health providers, we often find ourselves sifting through a lot of information about our clients and their experiences.  

We may be gathering information directly from our clients or from secondary sources, such as family members, parole officers, or specialists. It can often be difficult to sort between objective facts and opinions.

As providers, our instincts, speculation, and curiosity can be helpful tools in sessions with clients. However, well-written progress notes for social workers need to provide objective descriptions that are grounded in facts—prior to adding our clinical assessment or perspective. 

One of the most important reasons for this is respect for our clients. What we write is a medical record that can be used in legal proceedings, custody evaluations, and may be accessed by other healthcare professionals.  

Creating documentation that includes unbiased reports is one of the duties we have to our clients.

Be concise

When I was starting in the mental health field, I had a supervisor that would remind me “chances are your client’s treatment will not end with you.” This was often in response to my groaning about the time spent documenting each encounter with a client.  

Over the years, my supervisor’s words have rang true time and time again. 

For many clients we see, care may be ongoing or even lifelong. We need to use our documentation to ensure the next provider or auxiliary support is able to understand the issues that need to be addressed and the progress our clients have made.

Be expeditious

Social work is a demanding field, which can make it difficult to immediately document a client session or interaction. 

However, remembering vital information gathered in a session can become more and more difficult with each passing day.

In order to make sure we have high-accuracy documentation, keeping up with paperwork in a timely manner is a must.

Be protected

Since social work notes are medical records, they are privileged and confidential. Regardless of whether or not you’re working with insurance companies, all social workers are bound by the Health Insurance Portability and Accountability Act (HIPAA).  

Using secure and HIPAA-compliant electronic health care documentation can safeguard clients’ privileged information and protect clinicians from legal action. A HIPAA-compliant social work software, such as SimplePractice, can help with this.

How SimplePractice streamlines running your practice

SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.

If you’ve been considering switching to an EHR system, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.

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