Case notes are structured records documenting client or patient interactions, observations, interventions, and plans. They serve as essential tools for tracking progress, facilitating team communication, and meeting compliance standards like HIPAA in the US, GDPR in Europe, or PIPEDA in Canada and Australia.
In resource-constrained settings, justifying investments in better documentation practices is crucial. Data from the American Medical Association shows that physicians spend nearly two hours on paperwork for every hour of patient care, exacerbating burnout and reducing productivity. By using a sample case notes template, providers can cut documentation time by up to 50%, allowing more focus on patient outcomes. This guide provides case notes format with examples to help you create accurate, efficient records that support better care and justify tools like AI in healthcare.
A strong case notes template with examples should include key components to ensure completeness and usability. Here's a breakdown:
- Client/Patient Information: Basic details like name, ID, date of birth, and session date.
- Presenting Issues: A summary of the client's concerns or symptoms.
- Observations: Objective notes on behavior, appearance, and vital signs.
- Interventions: Actions taken, such as counseling techniques or referrals.
- Client Response: How the client reacted or progressed.
- Plan: Next steps, follow-up actions, and goals.
- Legal/Ethical Notes: Any confidentiality issues or mandated reporting.
Incorporating these elements into your case note writing examples helps maintain objectivity and relevance, reducing errors that could lead to audits or legal challenges.
Different professions favor specific formats for clarity and efficiency. Below, we explore the most common ones, complete with case notes examples and templates for real-world application.
The SOAP format is widely used in clinical and medical settings, integrating well with EHR systems like Epic, Cerner, or Allscripts. It's ideal for clinical case notes examples in healthcare.
Example for a Physician (Mental Health Case):
Patient Name: John Doe
Date of Visit: August 13, 2025
Age: 35
Gender: Male
Chief Complaint: "I've been feeling really down and anxious for the past few months."
The patient reports a 3-month history of persistent low mood, irritability, and anxiety, exacerbated by work stress and recent job loss. He describes difficulty falling asleep, averaging 4-5 hours per night, with frequent awakenings due to racing thoughts. Appetite has decreased, leading to a 10-pound unintentional weight loss. He denies suicidal ideation but admits to passive thoughts of "not wanting to be here anymore." No auditory or visual hallucinations reported. Past medical history includes mild hypertension managed with lifestyle changes; no prior psychiatric diagnoses or treatments. Family history positive for depression in mother. Social history: Married, two children, occasional alcohol use (2-3 drinks/week), non-smoker, works in IT (currently unemployed). He rates his mood as 3/10 today and anxiety as 7/10.
Vital signs: BP 128/82 mmHg, HR 88 bpm, RR 16/min, Temp 98.6°F, BMI 28.
Mental status exam: Alert and oriented x4. Appearance: Casual attire, adequate grooming, appears fatigued with dark circles under eyes. Speech: Normal rate and rhythm. Mood: "Anxious and sad." Affect: Congruent, restricted range. Thought process: Linear, no delusions. Thought content: No hallucinations or suicidal/homicidal ideation. Insight: Fair. Judgment: Intact. Cognition: Mini-Mental State Examination (MMSE) score 29/30. PHQ-9 score: 18 (moderate-severe depression). GAD-7 score: 15 (severe anxiety).
Major Depressive Disorder, moderate, with anxious distress (ICD-10: F32.1). Rule out Adjustment Disorder with Depressed Mood secondary to job loss. No evidence of bipolar disorder or psychotic features at this time. Contributing factors include recent unemployment and family history.
1. Pharmacotherapy: Start sertraline 50 mg daily for depression and anxiety; titrate as tolerated. Discuss side effects, including sexual dysfunction and GI upset.
2. Psychotherapy: Refer to cognitive behavioral therapy (CBT) specialist; schedule initial session within 2 weeks.
3. Lifestyle Interventions: Recommend daily exercise (30 min walking), sleep hygiene education, and mindfulness apps. Advise limiting alcohol.
4. Follow-up: Return visit in 2 weeks to assess medication response and PHQ-9/GAD-7 scores. Provide crisis hotline numbers; instruct to seek emergency care if suicidal thoughts emerge.
5. Labs/Tests: Order basic metabolic panel, TSH, and CBC to rule out organic causes.
6. Education: Provided resources on depression management; patient verbalized understanding.
This case notes format with examples ensures structured documentation, making it easy to share with multidisciplinary teams.
Popular among social workers and therapists, DAP combines subjective and objective data for brevity. It's a go-to for social work case notes template and therapy case notes examples.
Example for a Social Worker (Child Welfare Case):
Date: August 13, 2025
Time: 09:30 AM
Client: Jane Doe (12 years old)
Case Number: CW-2025-1234
Social Worker: Alex Smith, MSW
- Setting: Virtual home visit via video call due to family’s remote location.
- Participants: Jane Doe (client), Sarah Doe (mother), and social worker.
- Observations: Jane appeared engaged but reserved, sitting at the kitchen table with her mother. Home environment appeared clean and organized, with adequate food supplies noted. Jane’s affect was subdued, and she spoke softly when answering questions. Mother reported Jane has been attending school regularly but struggles with peer interactions.
- Reported Information: Mother stated recent improvements in Jane’s mood since starting therapy two weeks ago. Jane confirmed she feels “a little better” but expressed anxiety about an upcoming school event. No reports of safety concerns or immediate risks in the home. School counselor’s report (received 08/10/2025) noted Jane’s academic performance is stable but social withdrawal persists.
- Collateral Contacts: Contacted Jane’s therapist prior to visit; therapist noted Jane is beginning to process feelings related to past family stressors but needs continued support.
Jane continues to show signs of social anxiety and emotional guardedness, likely influenced by past family stressors (e.g., parental separation noted in case history). Her engagement in therapy is a positive step, and improvements in mood suggest early progress. The home environment appears stable, with no immediate safety concerns. Mother’s involvement is supportive, though she may benefit from additional parenting resources to help Jane with social skills. Continued monitoring is needed to ensure Jane’s emotional and social needs are met, particularly with upcoming school-related stressors.
1. Follow-Up Visit: Schedule next virtual home visit for August 27, 2025, to monitor Jane’s progress and home environment.
2. Therapy Support: Coordinate with Jane’s therapist to discuss strategies for addressing social anxiety, particularly related to school events. Request update before next visit.
3. School Collaboration: Contact school counselor by August 15, 2025, to discuss accommodations for Jane’s social anxiety during the upcoming school event (e.g., smaller group activities).
4. Parenting Resources: Provide mother with information on local parenting workshops focused on supporting children with anxiety by August 20, 2025.
5. Safety Monitoring: Continue to assess for any emerging safety concerns in the home during follow-up visits.
Next Steps: Social worker will email parenting workshop resources to mother and confirm school counselor contact. Jane encouraged to practice one coping strategy (e.g., deep breathing) before the school event, as discussed with therapist.
Use this case note writing template for social workers to focus on actionable insights without unnecessary details.
BIRP is excellent for behavioral health and counseling, emphasizing client reactions. It's common in counseling case notes examples and case note examples for counselors.
Example for a Counselor (Substance Abuse Case):
Behavior: Client arrived late, expressing frustration with relapse triggers.
Intervention: Explored cognitive behavioral techniques to identify triggers.
Response: Client engaged actively, reporting reduced urge intensity by session end.
Plan: Assign daily journaling; follow up via telehealth in three days.
This format supports progress notes vs case notes examples by highlighting immediate responses.
GIRP ties notes directly to treatment goals, making it suitable for long-term care in mental health case notes template.
Example for a Therapist (Depression Management):
Goal: Improve daily functioning by reducing depressive symptoms.
Intervention: Introduced mindfulness meditation exercises.
Response: Client practiced in-session and noted a 20% mood improvement.
Plan: Continue exercises at home; monitor via app; reassess in next session.
Often used in nursing or hospital transfers, SBAR is concise for clinical case notes template.
Example for a Nurse (Patient Handover):
Situation: Patient complaining of chest pain post-surgery.
Background: 65-year-old male, history of hypertension; surgery two days ago.
Assessment: Vital signs stable, but pain at 6/10.
Recommendation: Administer pain relief; monitor closely; consult cardiologist if persists.
This is tailored for mental health assessments in therapy session case notes sample.
Example for a Psychiatrist:
Predisposing: Family history of anxiety.
Precipitating: Recent job loss.
Perpetuating: Poor sleep habits.
Protective: Strong social support network.
Wondering how to write case notes with examples? Follow these numbered steps for effective documentation:
- Prepare Before the Session: Review previous notes and client goals.
- Document Immediately: Write within 24 hours to ensure accuracy—delays increase error rates by 30%, per a Journal of the American Medical Informatics Association study.
- Stay Objective: Use facts over opinions (e.g., "Client appeared tearful" vs. "Client seemed sad").
- Be Specific and Concise: Include measurable details, like "Anxiety reduced from 8/10 to 5/10."
- Link to Goals: Connect interventions to broader treatment plans.
- Review and Edit: Check for completeness and compliance.
- Use Tools for Efficiency: Leverage artificial intelligence tools to automate drafting.
For client case notes examples, adapt these steps to your field—social workers might emphasize family dynamics, while therapists focus on emotional responses.
In today's demanding environment, AI in healthcare and artificial intelligence in healthcare are game-changers for physician documentation. The best AI solutions, like S10.AI's AI medical scribe, act as digital assistants, transcribing conversations in real-time and generating structured case notes. This tool AI integrates seamlessly with any EHR—whether Epic, Cerner, Athenahealth, or others—across all specialties, from primary care to psychiatry.
Studies from Innovaccer show that AI scribes can save providers 2-3 hours daily on documentation, directly combating burnout. Imagine focusing on patient empathy instead of typing—AI and healthcare synergy at its finest. S10.AI's best artificial intelligence offering ensures compliance, accuracy, and customization, making it one of the top AI tools for productivity.
"As a busy clinician, integrating an AI medical scribe has been transformative. It frees me to connect with patients humanely while handling the paperwork flawlessly," says Dr. Emily Chen, a family physician in California. This echoes sentiments from thousands of providers using tools AI to reclaim their time.
Download our free case notes templates PDF for immediate use:
Customize them in Google Docs or integrate with your EHR. For advanced automation, explore S10.AI's solutions.
1. What’s the difference between progress notes vs case notes examples?
Progress notes track ongoing developments, while case notes encompass broader session records.
2. How often should I update my case notes?
Immediately after sessions, reviewing every 6-12 months.
3. Can AI help with therapy case notes examples?
Yes, best AI scribes like S10.AI generate compliant notes effortlessly.
Mastering case notes template with examples boosts efficiency, compliance, and patient care. From SOAP to GIRP, these formats—enhanced by AI in healthcare—tackle burnout head-on. Remember, tools like S10.AI's AI medical scribe work for all specialties and any EHR, proving the value of artificial intelligence in healthcare.
Ready to revolutionize your documentation? Request a free consultation today or learn more about our AI scribe.