1. Case Note Writing

2. Guidelines
Should be typed or written in black ink * never use white out
Should be in 3rd person (“This counselor,” “The client”)
Are always signed (M.Rush, MS, CPC, LMHP)
Are always dated (12/01/08)
Leaving no spaces (can a word or words be added)
Written using behavioral/descriptive terms (“The client shrugged his shoulders.”)

3. Guidelines Continued
Written without inferences (“The client was ambivalent.”)
Avoiding abbreviations and acronyms (MAST)
Using (continued) to continue from one page to the next page
Legible
Always grammatically correct (spelling, punctuation, etc.)
Errors are corrected with date and initials
Addendums
Done with immediacy

4. Guidelines Continued
If you miss a day, document absence and reason for it. Summarize what was talked about that day.
Organize chronologically