A good portion of a social work professional’s time is on administrative tasks such as documenting client progress. Writing case notes is part of the documentation needed to keep a complete client record.
Case Note Template Social Work
Case notes and mental health progress notes can easily get disorganized and difficult to follow if the social worker doesn’t use a consistent format for record keeping.
You can imagine trying to follow patient progress across multiple case notes if there is no organization to the session notes. It would be hard to relay the patient’s information to another healthcare provider, and the social worker themselves might spend hours trying to find the details they need.
There are several different framework examples of case notes for social workers. All can improve the process of writing case notes social work practitioners use. In this article, we’ll go through four of the most popular note formats.
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Table of Contents: DAP, BIRP, GIRP & SOAP Notes
Keep on scrolling down this page to read each section or click any link below to go directly to that section.
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What Are Social Work Case Notes?
Social work case notes are notes that a social worker writes to describe interactions with their client or patient. For example, when the social worker has a session with a client, they should document what happened during that session, how the client is feeling, how they appear, how they are progressing in their treatment, etc.
In social work terminology for case notes, the term progress notes is also used to describe this type of documentation. A case or progress note social work practitioners write is added to the client’s overall case record.
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These social work case notes example records tell an important story of the progress that an individual has made in their treatment plan and any incidents or details of importance that came up during meetings and engagements between the social worker and their patient.
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How Do You Go About Writing Case Notes?
If you want to write efficient and complete examples of social worker notes, then you should choose a consistent format for writing those notes. This means collecting the same categories of information each time and keeping the category sections in the same order.
Looking at sample case notes for case managers is a great way to get started writing and creating your own social worker social work case notes template to use. Once you’ve gone through some case note training – either formally or through your own research – choose a common framework for your social work case notes example.
Here are some things to keep in mind when choosing between popular notes formats, such as SOAP progress notes, the DAP note template, a BIRP notes PDF, or a GIRP notes template:
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Overview of 4 Popular Case Note Example Formats
There are many different examples of mental health case notes formats and case management progress notes examples. For this case note training article from Social Work Portal, we are focusing on four of the most popular case note example frameworks.
What is a “framework” or “case note format” exactly? It’s a way of organizing the case notes social work professionals use into sections. Using these same sections for all social worker case notes written for each session ensures uniformity in the way the details are collected and communicated.
You’ll see that there are some similarities between the four case note example formats. Each note name is an acronym for the sections they include. They will all have between three to four sections to keep notes targeted and concise.
The 4 social worker case notes formats we will review are:
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Next, we’ll get started with an explanation of the BIRP note template format.
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What Are BIRP Notes?
When writing sample BIRP notes for social work case work, you would use the format of: Behavior, Intervention, Response, Plan. This format is often used by clinicians providing mental health services.
After reading through the BIRP note example below with the description of each letter, you’ll find a BIRP progress note example that you can reference.
Behavior
In this section of the BIRP format, you would describe the overall behavior being exhibited by the client. This is divided into two areas, objective and subjective.
When describing behavior objectively in a BIRP progress note, the social worker will include facts and details that they observe. Such as the individual’s appearance or demeanor.
For subjective descriptions in BIRP case notes, the social work or clinician would include things that the client or patient says about how they are feeling, what they are thinking, and their general point of view.
Intervention
In this section of mental health BIRP notes examples, the social worker will describe what they did to help the individual reach their treatment plan goals. What intervention methods and activities did they employ during the session?
Response
In the response section of BIRP documentation, the clinician will note how the patient responded to the intervention. In this part of the BIRP note format, the social worker will also include details on the individual’s progress toward goals and milestones.
Plan
In this last section of BIRP notes, the social worker will document the next steps that are to be taken with this individual. This could include a notation of when the next meeting is or any changes to the treatment plan based on today’s intervention and response.
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BIRP Note Example
Do you have any questions about case noting, sample BIRP notes examples or where to find a BIRP notes PDF? Do you have feedback about a great dap note template or dap progress note example? If so, click here to contact the Social Work Portal Team.
What Are DAP Notes?
The DAP format has just three sections rather than the four sections the other social worker case note templates use. DAP clinical notes include the sections: Data, Assessment, Plan.
If you’re looking for sample DAP notes, you’re in luck. After we go through each section in DAP progress notes, we’ve included a DAP progress note example for you to review.
Data
In the data section of a DAP notes PDF or online template the social worker will add all the various data that they’ve observed and collected during this session.
What’s the DAP notes meaning of data? Here are some examples:
Assessment
In the DAP case notes assessment section, the social worker writes their assessment based on the data collected. It can include any diagnosis or change in diagnosis, how the client is progressing toward goals, etc.
Plan
DAP case notes include a plan section, along with the other three types of social work case notes. What does the social worker write in the DAP note format “plan” section? They should include the next steps in the client’s treatment plan.
They will also include any tasks they are assigning to the client, when the next session is planned, and any adjustments to the treatment plan.
DAP note is just one of many case notes that you can find in SWP’s Case Management Hub Portal.
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DAP Note Example
| Data: | Joseph is relaxed and his appearance is tidy and clean. He states that he still feels anxious when leaving his home, but he is “doing better.” He said he successfully visited the grocery store twice in the past week without experiencing a panic attack. But had an attack when he was in a large meeting at work and had to step out. |
| Assessment: | Joseph is progressing slowly, and his anxiety is beginning to interfere with his work. He is responding well to visualization techniques |
| Plan: | Joseph’s visits are being increased to twice per week, so we can improve his progress. I gave him a link to videos he can watch to learn mindfulness and visualization techniques to use when he feels anxiety increasing. |
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What Are GIRP Notes?
GIRP progress notes use a four-section case notes format. This is a goal-oriented framework, with the four sections in a GIRP progress notes example being: Goals, Intervention, Response, Plan.
As we have in other sections, we’ve included an example of good GIRP notes after we describe each section of the GIRP social work case notes framework.
Goals
In the first section of a GIRP notes sample, the social worker will describe the goals and objectives that were addressed in today’s session.
They will include the progress toward goals, how the individual is feeling about the goals and their steps to meet them, and the social worker’s observations about goals.
Intervention
In the intervention section of a GIRP notes template, the social worker will describe how they engaged with the client today to help them meet their treatment goals.
Response
In the response area, the clinician will describe the client’s response to the intervention. This GIRP notes section can also include the social worker’s observations and assessment of the client’s response to the intervention.
Plan
What is the next step? The GIRP progress notes plan section is for laying out the next step being taken to help the client reach their treatment goals, as well as any changes to the treatment plan.
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GIRP Notes Examples
| Goals: | Joseph met the goal of successfully visiting the grocery store twice in the past week without experiencing a panic attack. He feels proud of his progress. He is still having trouble in work settings during large meetings when his panic attacks come on. He admitted to not practicing the visualization techniques I gave him last session. |
| Intervention: | I led Joseph through mental visualization exercises and provided him with a video link so he can access these on his phone when needed. |
| Response: | Joseph was initially tentative about doing the visualization techniques correctly but became more comfortable with them by the end of the session. I encouraged him to try them when he next feels a panic attack coming on. |
| Plan: | Joseph’s next visit is in 4 days. His visits are being increased to twice per week, with the goal of accelerating his progress. |
Do you have any questions about GIRP notes examples, or the difference between GIRP notes examples and a BIRP note example? Or do you have feedback about the best dap progress notes taking techniques that has worked well for you? If so click here to contact the Social Work Portal Team.
What Are SOAP Notes?
The fourth popular template for case notes social work practitioners use is the SOAP note format. The SOAP notes meaning for the acronym is: Subjective, Objective, Assessment, Plan.
After you’ve learned about the parts of a SOAP note, you’ll find a SOAP progress notes example that you can reference.
Subjective:
The first section of SOAP notes is to document subjective information gathered from the patient or client during this session. This may include their feelings, current attitude, and how they are progressing in their treatment plan from their point of view.
In the case of a family group session or a session with a child or adolescent, the subjective section of the SOAP notes meaning can also include input from family members, parents, and caretakers.
Objective:
Next is the objective section of the soap notes template. This is where a social worker will document their objective observations. This can include the client’s demeanor, appearance, and other fact-based and observable data related to this session.
Assessment
The assessment section of SOAP progress notes is where the social work professional will summarize the session and give their overall assessment of what occurred and how the client is progressing in their treatment.
Plan
The SOAP notes meaning for the plan section is the same as for the other case management notes types. This is where the social worker will describe the next steps that are to be taken with the client, and any adjustments to the intervention and treatment plan.
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SOAP Notes Example
| Subjective: | Joseph said he still feels anxious when leaving his home, but “it is better” since our last session. He still has panic attacks when he is in crowded situations. The ones at work are the worst for him. He said he thinks the mental visualization tips help, but he has only tried this “once or twice.” |
| Objective: | Joseph is more relaxed this session than he was at the last session. He has successfully visited the grocery store twice in the last seven days without experiencing a panic attack. |
| Assessment: | Joseph is making progress, but it’s slow. He has achieved one of the three goals that we discussed. More focus on learning visualization techniques should help his progress. |
| Plan: | Joseph’s visits are being increased to twice per week, so we can spend more time practicing visualization techniques and improving the speed of his progress. |
Please let us know if you have any questions about DAP notes, the SOAP notes meaning, or sample BIRP notes, soap notes examples, or GIRP notes. Also, do you have feedback about the best dap format and techniques that has worked well for you? If so, click here to contact the Social Work Portal Team.
Conclusion | Overview of BIRP, DAP, GIRP, and SOAP Note Format
Whether you gravitate towards a DAP note example, the SOAP note format, or another format for social work case notes, using a template like these can improve the efficiency of your case management notes.
It’s a good idea to familiarize yourself with several different case note example formats so you can try them out and see which you like best. Another reason to learn the different formats of case notes social work and medical professionals use is so you’ll understand notes written by colleagues that may be in another format.
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We hope this overview of DAP notes, BIRP notes, GIRP notes examples, and the SOAP note format has been helpful. If you have any questions about any social work case notes examples, please don’t hesitate to let us know.
We would love to hear from you. Do you have feedback on a best case note template social work leaders use, case noting, or additional examples of mental health case notes? If so, click here to contact the Social Work Portal Team.
FAQ | Case Management Notes Examples
Social work case notes are notes that a social worker writes to describe interactions with their client or patient. For example, when the social worker has a session with a client, they should document what happened during that session, how the client is feeling, how they appear, how they are progressing in their treatment, etc.
If you want to write efficient and complete examples of social worker notes, then you should choose a consistent format for writing those notes. This means collecting the same categories of information each time and keeping those category sections in the same order.
Some of the information included in social work case notes is:
•The patient’s feelings, observations, and experiences
•The social worker’s objective observations
•An assessment of the information gathered during the session
•Progress towards goals
•Interventions that the social worker provided during the session
•Next steps in the client’s treatment plan
•Any changes to the client’s treatment plan
The 4P Factor Model is another type of case notes framework. It considers four items, all beginning with P, for each biological, psychological, and social factor.
The 4Ps are:
• Predisposing factors
• Precipitating factors
• Perpetuating factors
• Protective factors
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