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Progress Notes/Logs

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Lindsay Shepard

on 20 November 2013

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Transcript of Progress Notes/Logs

Progress Notes/Logs
Progress notes/logs are documents maintained by social agencies and organizations, wherein individual client's care and progress are tracked per interaction by their assigned worker.

***'Note' & 'Log' tend to be used interchangeably, but can also be agency-specific.
Document interactions and progress (for stakeholders)
Other workers/collaborators
Third parties (e.g., court, etc.)
Track/evaluate progress
Contents & Format
Each agency and organization may have its own policies for documentation, but there are some general standards for contents and format...
How to Write a Case Note/Log
Be thoughtful & plan what needs to be recorded and how
State the objective/goal of the interaction
Describe how the client(s) present ("client reported..." or "as evidenced by..."
Record the client's reported progress (action compliance, reported successes/issues, etc.)
Describe reports, discussions, activities, etc.
Report observations ("based on...")
Record assignments, next steps, and plans for follow-up.
The information relevant to the present interaction, such as:
Current presentation
Assessment/history information (e.g., reported cultural differences)
Reports & check-in since the last interaction (e.g., progress, issues, etc.)
Actions/work/activities/conversation on the presenting problems
Reflections & observations (e.g., "the client seemed stressed as evidence by...")
Homework assigned and plans for the next interaction
Format & Style
Use discretion (records are available to clients upon request & are often shared with other stakeholders)
Be objective!
Write clearly!
Document all
info with particular emphasis on what was reported and what was done
No labels, personal opinion, conjecture, excessive detail, or extraneous info
Provide evidence and sources of claims
Use tentative language for observations
Document strengths as well as limitations
Full transcript