7
Documentation Skills for Community Health Workers
SLIDE 17
Distribute and refer to the SOAP note handout.
Emphasize that the Subjective section should include what the client tells us.
Objective data includes what we can observe that is measurable and describable—
what did we see, count, hear, smell or measure?
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§ Assessment: your opinion or interpretation of the client’s
situation as reported and based on what you observe.
§ Example: Client upset about possible loss of housing and
its effects on client’s health.
§ Plan: What do the client and CHW want to do to resolve the
issue or situation? How will it be accomplished? Who will do
what ?
§ Example: Provide emotional support regarding fear of losing
housing. Rule out other causes of eviction and agitation.
CHW will prepare referral to housing advocate to minimize
disruption and provide hope for new housing option. Client
will gather proof of income, etc. to prepare for housing
meeting. CHW will update care plan with new housing goal.
Case Notes
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SOAP Notes: S = Subjective O = Objective
A = Assessment P = Plan
§ Subjective Data: What the client (or significant other) tells
us about their condition
§ Example: Client reports great concern about losing
housing - owner is losing the property. Client reports not
sleeping well, no appetite, and doesn’t know what he’s
going to do.
§ Objective: What you observe or find during the CHW visit.
§ Example: Client is visibly upset (crying, frantic speech,
pacing, shifting in the seat often)
Case Notes
SLIDE 18
The Assessment section should include what is happening and/or needed with
theclient.
The Plan is the joint plan of action for the CHW and the client.
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Case Note Considerations
§ Collaborative: Will you be writing down the case notes in the
moment so that the member of the care team can review them, or
afterwards? Consider doing a check in with your supervisor or
other care team member to reflect back what you hear before
writing it down.
§ Timeliness: As soon as possible after the encounter, outline the
strengths and challenges that you heard.
§ Participant records: Whatever you write becomes a record of the
client; don’t write anything you couldn’t verbally say. Remember
that the client is the owner of their own record and that others who
have access to their case notes will react based on what was
written.
§ Non-judgmental: Try to not interpret their behavior or be
judgmental.
Case Notes
SLIDE 19
Review the slide.
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Case Note Considerations (cont.)
§ Confidentiality: Remember not to identify others by name in a
participant’s record; describe them by relationship. Keep HIPAA and
other personal identifying information safe, particularly when in transit.
§ Risk assessment: One function of documentation is to note risks and
your responses to them, for the protection of the client, yourself, and
your organization’s legal protection.
§ Track sessions and appointments: Documentation helps us track a
client’s progress, and helps us keep continuity from meeting to meeting
by helping us remember and review what has already happened.
§ Amending notes: Use appropriate methods of amending notes, by
making corrections and signing your notes.
§ Organization: Keep your case files organized and write legibly.
Case Notes
SLIDE 20
Review the slide.