A social work case note records one contact with a client: who was there, what you did, how the client responded, and who does what next. Copy the free template, see filled examples from hospital and community practice, and check what each part needs.
SOCIAL WORK CASE NOTE Client: [Name] Date of birth or ID: [Identifier] Date and time: [Date, start and end time] Social worker: [Name, credentials] Program: [Hospital unit, community agency, school, or other program] CONTACT DETAILS Contact type: [Home visit, office, phone, video, bedside, or community] People present: [Client and others, with their role or relationship] Consent: [Consent to share information, with whom, and any limits] Purpose: [Why the contact happened, linked to the client's goals or case plan] OBSERVATIONS Client presentation: [Appearance, mood, behavior, and engagement, as observed] Environment: [Home or setting conditions, safety, basic needs, accessibility] Client's report: [Needs, changes, and priorities, in the client's words on key points] INTERVENTIONS Resource linkage: [Referrals made, applications started, programs contacted] Advocacy: [Contacts made on the client's behalf, and the outcome] Counseling and support: [Supportive counseling, problem-solving, education] Care coordination: [Team members and services coordinated] CLIENT RESPONSE Response: [How the client responded, what they agreed to, and any concerns or disagreement] COLLATERAL CONTACTS Collateral: [Person or role, agency, method, what was shared or learned, consent on file] SAFETY CONCERNS Risk screen: [Self-harm, harm to others, abuse, neglect, exploitation, or none identified] Actions taken: [Safety planning, reports made as the law requires, supervisor consulted] TASKS AND NEXT STEPS Task 1: [What, who is responsible, due date] Task 2: [What, who is responsible, due date] Task 3: [What, who is responsible, due date] Next contact: [Date, type, and purpose] Signed: [Social worker name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
The facts of the contact: how it happened, who was there, and why.
Avoid: Leaving out who was present. It affects what the client could say freely, and who now knows what.
What you saw and heard, kept apart from your interpretation.
Avoid: Labels such as “uncooperative” or “dirty home.” Describe the behavior or condition you saw instead.
What you did in this contact, named specifically.
Avoid: “Provided support” on its own. Name the intervention and what it was for.
A short record that you screened for risk, what you found, and what you did.
Avoid: Leaving it blank. Write “none identified” after screening, so a reader knows you asked.
Who does what, by when. It is the part a covering worker reads first.
Avoid: Tasks with no owner. “Follow up on housing” doesn’t say who will do it, or when.
Describe what you saw and heard, not labels. “Did not answer the door at two scheduled visits” helps the next worker more than “noncompliant.”
Every next step needs a who and a when, including the client’s own tasks. That is what lets a covering worker pick up the case.
Record the consent in place before you shared or gathered information, or the legal basis if you acted without it.
If you screened for risk, abuse, or neglect, say so even when nothing was found, and record any report made, with the time and agency.
Clients, courts, and other agencies may read case records. Include what bears on the goals and risks, and leave out third-party details the record doesn’t need.
After a home visit or a call, dictate what happened. Vero Scribe writes the case note in your template, with each task’s owner and due date, for you to review, edit, and copy into your records, or export to PDF or Word.
The contact type and who was present, the purpose, what you observed, your interventions, the client’s response, collateral contacts, safety concerns, and the next steps with owners and due dates.
The terms often overlap. A case note can record any contact, including calls and collateral contacts, while a progress note usually follows a session and tracks progress toward goals. This template works for both.
Describe the behavior and conditions you observed, quote the client on key points, and name the source of anything you were told. When you give a professional opinion, label it as one.
A contact with someone other than the client about the client’s situation, such as a family member, landlord, school, or another agency. Record who, how, what was shared, and the consent that allowed it.
As soon as you can, ideally the same day. Notes written close to the contact are more accurate, and many agencies set a deadline.
Yes. Copy it, or download it as a Word or text file. No account needed.
SOAP for psychosocial work: client report, observations and collateral, needs, and referrals.
Case notes, care plans, and documents drafted from your conversations.
A workflow, worked examples, and a quality checklist.
Worked notes in several formats, with checks before you sign.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
No credit card required. 10 free actions every month.
Social work case note: discharge planning for an older adult
Hospital medical unit, bedside visit
Contact details
Bedside visit, 35 minutes. Present: the patient, a 79-year-old man on day 5 of an admission for pneumonia, and his daughter by speakerphone, with his consent. Purpose: discharge planning; the team expects him to be ready in 1 to 2 days.
Observations
Sitting in a chair, dressed, alert, and engaged; asks clear questions. Physical therapy reports he walks with a walker and needs standby help on stairs. Lives alone in a second-floor apartment with 12 stairs and no elevator. “I want to go home. I’m not going to a nursing home.”
Interventions
Reviewed the team’s recommendations: a walker, supervision on stairs for the first week, and therapy at home. Discussed options: home with services, a short rehabilitation stay, or staying with his daughter. Referred for home nursing and physical therapy visits. Requested a shower chair and raised toilet seat through occupational therapy. Gave information on a meal delivery program and a medical alert button.
Client response
Chose to go home with services and could explain the risks, including falls. Agreed to the walker, the alert button, and his daughter staying for the first 3 nights. Declined meal delivery for now; will reconsider after the first home therapy visit.
Collateral contacts
Daughter, by phone, with his consent: will stay for the first 3 nights and drive him home. Home care intake, by phone: referral received; first visit expected within 2 days of discharge. Unit nurse and physician told of the plan.
Safety concerns
High fall risk, addressed by the equipment, therapy, and supervision above. Cognition intact on the occupational therapy screen. No concerns about abuse, neglect, or self-neglect.
Tasks and next steps
Social worker: confirm the home care start date by noon tomorrow. Occupational therapy: deliver the equipment before discharge. Daughter: prepare the spare room and collect the new prescriptions on the day of discharge. Next contact: bedside visit tomorrow morning, with his daughter by phone, to confirm the plan.