Lesson 5.4

Writing Effective Case Notes

Associate stacking books

Lesson Preparation

Before coming to your training, please do the following:

  • Read Doctrine and Covenants 128:3.
  • Bring printed copies of several case notes you have written.
  • Review “A Suggested Formula for Writing Case Notes,” found in the “Lesson Resources” section, Resource 1.

Lesson Preview

Part of our employment involves documenting progress, difficult scenarios, and problems that arise with our associates. At times writing case notes can be confusing and daunting. However, it is important to learn the eternal principle of record keeping. This lesson will discuss why we write case notes, demonstrate the power of positive case notes, and give you a formula to follow as you practice writing them.


Defining the Why, What, Where, and When of Case Notes

From the following list, choose and complete one or more activities that best apply to your situation.

Video Icon
Activity 1

Watch the video “Teachings of Wilford Woodruff: The Importance of Record Keeping.” As a group, discuss the following questions:

  • What is the importance of record keeping?
  • How does the importance of record keeping in the Church apply to you and the associates you work with?
  • What should be recorded in a case note?
  • What should you avoid when writing a case note?
  • Where should case notes be recorded?
  • Who should be writing case notes?
  • How often should you write case notes?
  • What does it mean to write a “timely” case note? How have keeping and reading case notes helped you better assist an associate?
  • When you use the case management software (DECM), when should you use a sticky note instead of a case note?

Group Icon
Activity 2

Read D&C 128:3.

As a group, discuss the following questions:

  • What did Joseph Smith request in his letter to the Saints?
  • What are some parallels between Joseph’s request and writing case notes?
  • Why is it important to write case notes?

As you discuss this last question, list the reasons on the board, and share a few examples to support your points.

Then, continue discussing:

  • How often should you create case notes?
  • What should you include in a case note?
  • What should you avoid including in a case note?
  • Where should you record case notes?
  • When you use DECM, when and how should you use sticky notes?

Group Icon
Activity 3

As a group, discuss:

  • From your reading and experience, why is it important to write case notes?

As a group, review “How to Write Case Notes” in the “Lesson Resources” section, Resource 2. Then discuss:

  • How would you define a case note?
  • What should be included in a case note?
  • What should not be included in a case note?
  • Where should you record case notes?
  • When or how often should you record case notes?
  • From your reading and experience, why is it important to write case notes?
  • What questions do you have about the importance of case notes?
  • When you use DECM, when and how should you use sticky notes rather than case notes?

Recognizing the Power of Positive Case Notes

From the following list, choose and complete one or more activities that best apply to your situation.

Video Icon
Activity 1

Watch the video “O Remember, Remember” (Mormon Messages, lds.org). As you watch, consider the following questions:

  • What did President Eyring do when his children were small?
  • What question(s) did President Eyring ponder?
  • What else can you learn from President Eyring’s message?

As a group, discuss the questions above. Then discuss the following:

  • In your opinion, how would regularly recording positive experiences—seeing the “hand of the Lord”— impact your life and change your perspective as you work with associates?
  • What could positive case notes include?
  • How are you using “Success Indicators” in DECM?

As the group discusses, have a volunteer write several examples on the board.

Individually, take time to look at some of the case notes you have written for the associates you work with and ponder:

  • Are your notes mostly positive or mostly negative?
  • Have you written any positive notes lately for those associates?
  • Have you seen God’s hand in any of your associates’ lives recently?

Write impressions in your learner's journal.

Write Icon
Activity 2

In your learner’s journal, take a few minutes to write something positive about two of the associates you work with (one per page). This could be a quality, an improvement, an achievement, or something good that happened to them recently. When time is up, each of you take turns to share your positive notes with the rest of the participants.

After everyone has had a chance to share, as a group, discuss:

  • When thinking about case notes, why is it important to record associates’ positive qualities, achievements, etc.?
  • What impact does it have on you when you recognize associates’ positive attributes, improvements, achievements, etc.?
  • What impact does it have on associates when you recognize such things?
  • What do positive case notes look like?
  • How does reading positive case notes impact you?
  • How have you used “Success Indicators” in DECM and what has been the impact on you and your associates?

Practicing How to Write Effective Case Notes

From the following list, choose and complete one or more activities that best apply to your situation.

Write Icon
Activity 1

Writing effective case notes can be difficult. As a group, read Resource 1 of the “Lesson Resources” section, which contains a suggested formula for writing effective case notes, including examples. Then discuss:

  • How can focusing on three main items simplify the process of writing case notes?
  • How can following this formula lead to writing effective case notes?
  • What questions do you have about following this formula?
  • What additional insights or advice do you have about following this formula for writing case notes?

Individually, choose one or two of the case notes you have written. Rewrite them in your learner's journal, following the suggested formula. Then, share your case note(s) with a partner and give each other feedback.

As a group, discuss:

  • How are your rewritten case notes different from the originals?
  • What were some of the challenges of writing case notes following this formula?
  • What could help you overcome such challenges?
  • What additional advice do you have about writing effective case notes?
  • In DECM, when should you use sticky notes rather than case notes?

Group Icon
Activity 2

As a group, take a few minutes to review “A Suggested Formula for Writing Case Notes,” found in the “Lesson Resources” section, Resource 1. Ask any questions you have about following this formula. Discuss additional items you feel are helpful in writing effective case notes.

Read the three sample case notes given in Resource 3 of the “Lesson Resources” section. After reading the examples, discuss:

  • Based on the formula in Resource 1, which of these examples is the most effective case note? Explain.

Individually, think of a recent event or situation with an associate (you may use the case notes you brought). Using both Resource 1 and the example from Resource 3 you just discussed as references, write an effective case note in your learner's journal. Then, share your case note with a partner and give each other feedback.

As a group, discuss:

  • How is your new case note better than the original?
  • How well does it follow the formula?
  • What, if anything, is missing from the case note, even if it follows the formula?
  • What did you learn from sharing your case notes?
  • What questions do you have about writing effective case notes?
  • What additional advice do you have concerning writing effective case notes?
  • In DECM, when should you use sticky notes rather than case notes?

Ponder and Plan

“What Lack I Yet?”

Seek to identify a personal or business gap or need.

Spend a few minutes silently pondering what you've discussed during this lesson. Listen as the Holy Ghost helps you identify areas where you can improve. Record your impressions in your learner's journal under the question “What Lack I Yet?”

“What Must I Do?”

Seek ways to close the gap or develop the required talent(s) to meet the need.

With the guidance of the Spirit, create your plan of how you will improve and close the gap(s) you have identified. You may use one or more of the exercises below, your own strategy, or a combination of both. Record this plan in your learner's journal under “What Must I Do?”

  • Find a positive case note you have written about an associate, and share it with him or her.
  • Practice writing effective case notes: Throughout the week, write three case notes following the suggested formula. Show them to your development counselor and get feedback to improve on this skill.
  • Practice using sticky notes and Success Indicators in DECM.

After a few minutes, those who are comfortable doing so can share their impressions with the group.

“Therefore, What?”

Seek understanding, and then share what you learned.

During the week, focus on implementing the plan you created. Record your impressions or lessons learned in your learner's journal under “Therefore, What?” You will be given time at the beginning of next week's lesson to share your experience with the group.

President Wilford Woodruff

“It may be considered by some not important to write or keep a record of our work or the work of God, but I believe it is. Otherwise the prophets would not have been moved upon to exhort us to faithfulness upon this subject. The Lord has told us that what we seal on earth shall be sealed in heaven and what we record on earth shall be recorded in heaven, and what is not sealed or recorded on earth is not sealed or recorded in heaven [see D&C 128:7–8]. Therefore it appears to be very important that we do keep a true and faithful record in all things.”

Journal of Wilford Woodruff, March 17, 1857

Lesson Resources

Resource 1

A Suggested Formula for Writing Case Notes

When writing a case note, you can use the following formula:

INCIDENT: What happened?

TRAINING/SUMMARY: A summary of what was said or the type of training that already took place.

RESOLUTION: What goal was set or action agreed on? What is the plan?

Example 1

INCIDENT: I spoke with Tina Gonzalez today (9/7) about concerns that multiple people have reported to me, saying that she stands too close to people when talking to them, causing them to feel “uncomfortable.” I have also experienced that first-hand. TRAINING: I told her to imagine that she has a hula-hoop around her midsection and that she should not get closer to a person than the hula-hoop would allow. RESOLUTION: She said she understood and would be more conscious of others’ personal or intimate space.

Example 2

INCIDENT: The associate was 24 minutes late on 1/13. This was the fourth time he was tardy in the last two weeks. TRAINING: Associate and job coach trainer discussed ways to avoid being late, such as checking his bicycle the night before to make sure that it works properly, going to bed early, and getting things ready the night before. They reviewed the AWARE form as well. RESOLUTION: Associate will make sure that his bike is working properly the night before.

Resource 2

How to Write Case Notes

Write case notes that are:

  • Clear
  • Concise
  • Accurate and objective
  • Timely
  • Readable, with acceptable grammar

Case notes should:

  • Describe behaviors
  • Record statements
  • Record observations

Case notes should avoid:

  • Diagnoses
  • Clichés
  • Street talk
  • Stereotypes and prejudices

Strong verbs to use:

  • Advised
  • Focused
  • Assessed
  • Identified
  • Assisted
  • Recommended
  • Clarified
  • Referred
  • Reflected
  • Structured
  • Discussed
  • Summarized
  • Directed
  • Supported
  • Encouraged
  • Urged
  • Trained

Words to Avoid:

  • Abnormal
  • Impulsive
  • Abusive
  • Irrational
  • Anxious
  • Overwhelmed
  • Dangerous
  • Resistant
  • Delusional
  • Suicidal
  • Demanding
  • Threatened
  • Disturbed
  • Troubled
  • Hysterical
  • Uncooperative
  • Immature
  • Unfit

Resource 3

Sample Case Notes
  1. 1 Jane called in sick today. She was vague in her responses when I asked her about her sickness and why she felt she could not come in. This is the third time this month this has occurred. I wonder if this is pretty common for her to avoid work, and if this is the reason why she has not been able to keep a job. We had discussed her attendance needing to improve during our R&D meeting on May 15. I reviewed attendance standards on the AWARE form with her, making sure she understood the importance of being reliable in her attendance. We agreed on an action step goal that she would not miss any days for the next two weeks. We also added a milestone for her attendance to be at industry standard three months from now. We agreed that she would earn five DI dollars each time she met the two-week attendance goal. In that meeting she reaffirmed she wants to improve in this area. I wonder if missing work is normal to her or if there is something else going on in her life that she is not yet willing to share with me, like whether she is troubled or anxious or something. I will check with her mentor and ask the development counselor to contact the bishop. I am sad she did not successfully complete the attendance action-step goal. When she is here at work, she stays on task and works with a lot of energy. I will sit down with Jane the next time she comes in to review the milestone and action steps to identify other steps we can take to help her achieve her goals.
  2. 2 Jane—sick 6/14. Also sick on 6/1, 6/2, and 6/7. I had met with Jane on 5/15 and set an action step goal with her to not miss any time over the next two weeks. I advised her to improve her attendance so that she could participate in other desired skills training. Based on what I can gather from her responses, there appears to be no clear reason for missing work. I encouraged her to come on time to work and provided an incentive for the next week if she would improve. I am still investigating the possible reasons for her missing work, including contacting her mentor. More severe consequences or a different method of reward may need to be in place to help her improve.
  3. 3 Jane has called in sick multiple times in the last few weeks (6/1, 6/2, 6/7, and 6/14). Today we discussed the importance of work attendance and identified reasons for her reported sicknesses. Jane said she understood the importance of coming to work. We set an attendance goal for the next week, with a reward of five DI dollars, based on her progress.