Different types of case notes

Clinical Session Notes

Clinical notes should be brief and factual, containing concise details of what was discussed in session, and not the personal opinions of the therapist. Any referrals or other action taken regarding the session should also be documented in this type of notes.

Since the primary purpose of session notes is to support our work with the client, session notes typically contain:

  • Date and time of attendance and session number
  • A summary of what the client shared and what was objectively observed by the practitioner
  • A record of interventions used by the practitioner
  • A record of any strategies pursued and any actions taken, with an explanatory note for such actions
  • Any correspondence and contact since the previous session
  • Any homework set
  • Details if a referral has been made
  • Plan for future sessions.

In writing our session notes the question to ask is; “if I were to be called upon by a court to divulge my notes, would they be adequate and defensible?” If in doubt, supervision provides a safe space for discussion.

Group Session Notes

Notes for group work may differ from those described above and may include:

  • A group summary or outline, identifying information for each member of the group
  • Objective information on each member’s mood and body language
  • Notes on each member’s participation, behaviour and response to other group members
  • A description of issues and events between the members of the group
  • Objectives and goals for each group member and how each member might achieve them
  • Interventions used to address each client’s goals
  • Responses of individual members, for example, feedback and suggestions about the process
  • Plans for future sessions, including homework for each member.

Process Notes

Process notes are different from session notes; they are written by the therapist for use in supervision or for personal reflection.

Process notes often take a journal-like form, focusing on the process between therapist and client, and the counsellor’s own thoughts and feelings in the work. They may take the form of just a few key words to remind you of the issues you wish to reflect on and/or take to supervision. They can be a useful tool for reflection and need not be factual.

Some counsellors don’t actually write process notes but instead rely on their memory to store such information. If you do choose to write process notes, they should be anonymous – written in a way that completely disguises the client beyond recognition.

Unlike session notes, they can’t be requested by the client. However, if a judge or coroner becomes aware of the existence of process notes, they have the legal power to order their release so it is important to keep the existence of these notes a secret and for personal use only. 

Case Conceptulisation

In psychology and related disciplines, a case conceptualization compiles an evaluation’s essential facts and findings to inform recommendations.

While it typically pertains to evaluating an individual, the concept can also be applied to summarizing findings about a group or organization.

Using the insights from a case conceptualization, recommendations can be formulated to enhance a client’s self-care, mental health, job performance, and more (Sperry & Sperry, 2020).

 

References:

  • Sperry, L., & Sperry, J. (2020). Case conceptualization: Mastering this competency with ease and confidence. Routledge.