Case Documentation

 Write That Down: Case Documentation

Purpose of Assignment: Practice professional documentation

Transferable Skill: Communication

In the human services profession communication includes displaying capability in writing, reading and oral communication, as well as the understanding of nonverbal language. The legal aspects of this profession require effective communication in both reading and writing legal documentation in addition to communicating within proper legal frameworks.

Instructions:

Part I

Consider the following scenario:

Amber, a 20-year-old college student is seeking mental health services for depression at the local community mental health center. During your meeting with Amber, she states that she has suicidal thoughts and has a bottle of Ambien in her apartment which she has considered taking to end her life. Because Amber is distraught and cannot commit to a safety plan you suggest that she be hospitalized psychiatrically for her safety. Amber states that she does not want to be hospitalized and has no intention of signing papers for voluntary hospitalization. She ultimately refuses and walks out of the agency’s front door.

In a two-page paper include the following.

You are the human service worker who completed Amber’s intake. You must now document the facts of your meeting with Amber. Write a case note addressing the following:

• Time and date of the event. (This can be fictional).
• Summary of the meeting.
• Discussion with the supervisor.
• Plan of action now that the client has walked out of the agency.

Part II

Explain your legal obligations in this scenario and any exceptions that might apply to client confidentiality.

Remember, writing in the third person means not using I, me or my in the case note. You can say things like, “The client reports that she…” “Supervisor was contacted and made aware of the situation.”