Creating Case Notes
Whether you are a mental health or a school counselor, taking careful case notes is an important part of your counseling process. Good case notes not only help you keep track of the work that you are doing with your client or student, they also protect you.
For this discussion, once again review the case vignettes in the presentation, Ethical Issues in Record Keeping and Technology, in this unit’s study. Select one vignette and use it to discuss the following:
- Write a case note using the SOAP or DAP format that is presented on page 140 of your text, Ethical, Legal, and Professional Issues in Counseling. You may need to be creative and enhance the case study in order to write a comprehensive case note.
- Provide a summary of how you decided what information to include or exclude.
Support your summary with support from the unit readings. Follow current APA style and formatting guidelines in your post.
Respond to the initial discussion posts of two other learners. What reactions do you have to the ideas the learner has presented? Include examples from your own experience to support your perspective, and raise questions to continue the dialogue.
This activity will help you achieve the following learning components:
- Identify the steps in addressing issues related to using technology in the counseling profession.
- Learn about different types of professional communication.
- Determine the proper application of APA formatting requirements.
- Discussion Participation Scoring Guide.
- Ethical Issues in Record Keeping and Technology | Transcript.
- APA Style and Format.