Case Notes and Progress Note Form

Records each client interaction, services provided, observations, and next steps in a defensible narrative format. Used by case managers for daily documentation.

Note Identification

• Date of Contact / Service
  The actual date the interaction or service occurred — not the date this note is being written.
• Time of Contact
  Start time of the interaction.
• Case Manager / Author Name
• Title / Credential
• Client / Case ID
  Use the assigned case number. Do NOT enter the client's full name or SSN in this field.
• Program / Service Line

Contact Details

• Type of Contact
• Location / Setting
• Duration of Contact (minutes)
  Billable and non-billable time combined. Enter whole minutes.
• Participants Present
  Select all who participated in this contact.
• Was an interpreter used?
• Language Interpreted

Presenting Situation and Observations

• Client Presentation / Affect
  Select all descriptors that apply based on direct observation during this contact.
• Reason for Contact / Presenting Issue
  Briefly describe the purpose of this contact or the issue the client raised. Use the client's own words where appropriate (use quotation marks).
• Safety Concerns Identified
  Includes risk of harm to self, harm to others, domestic violence, child/elder abuse, housing instability, or food insecurity.
• Safety Concern Description and Action Taken
  Describe the concern, your assessment, and any mandatory reporting or safety planning actions taken. Reference applicable policy (e.g., mandated reporter obligation under state statute).

Services Provided and Interventions

• Services / Interventions Provided
• Narrative Description of Services
  Provide a clear, factual narrative of what was done, discussed, or decided. Write in past tense. Avoid jargon. This is the core of the defensible progress note.
• Referrals Made This Contact
  List any referrals initiated during this contact.
• Client Response to Services / Interventions

Progress Toward Goals and Next Steps

• Progress Toward Care Plan Goals
• Barriers to Progress Identified
  Select all barriers observed or reported during this contact.
• Action Steps for Client
  List specific, measurable tasks the client agreed to complete before the next contact.
• Action Steps for Case Manager
  List specific follow-up tasks you will complete. Include target dates where applicable.
• Scheduled Follow-Up Date
  Date of next planned contact or check-in with client.
• Current Case Status

Supervisor Review and Attestation

• Is supervisory review required for this note?
• Supervisor Name
• Supervisor Comments
• Author Attestation
  By checking this box, you attest that the information in this progress note is accurate, complete to the best of your knowledge, and was documented in accordance with your organization's documentation policy and applicable professional standards (CMSA Standards of Practice; NASW Code of Ethics).