Handy List of Words for Healthcare Workers

As a healthcare worker, you are required to keep case notes. It’s important to maintain detailed records through case documentation. It allows you to create successful outcomes for your clients. Always make sure your case notes are useful. Do your best to make sure they provide insight and value. Analyze your notes and see if they would be useful to another case worker. You want to make sure you give an accurate picture of the client’s history, as well as their current situation.

It’s important to use language that is non-judgmental. Neutral language is the most common form of case notes in social work. It’s also helpful if you avoid making assumptions and remember to stick to the concrete facts. You should always indicate clearly when a comment is an observation. It is imperative you make it clear when you are recording the client’s own words by using quotation marks.

Notes are important in this type of work because the courts can subpoena records and other reports; you have to be careful about what you say about your respective client. Write your case notes immediately after you have spoken with a client. Here’s a handy list of words that many social workers use while writing up their case notes:

• Acknowledged
  Actively Listened
  Addressed
  Advised
  Advocated
  Asked
  Assisted
  Challenging
  Checked In
  Clarified
  Collaborated
  Commended
  Confronted
  Conducted
  Conveyed
  Crisis Intervention
  Developed
  Educated
  Empathized
  Empowered
  Encouraged
  Ensured
  Established
  Explained
  Explored
  Expressed
  Facilitated
  Focusing/Refocusing
  Framing/Reframing
  Goal (setting)
  Development/Goal Setting
  Guided
  Highlighted
  Honoring
  Identified
  Information Giving/Gathering
  Informed
  Interacted
  Interpreted
  Joined
  Modeled
  Observed
  Physical Activity
  Played
  Praised
  Presented
  Probed
  Problem Solving
  Prompted
  Rapport-building
  Recapped
  Recommended
  Redirected
  Reflected
  Reflective Listening
  Reframed
  Reinforced
  Reiterated
  Reminded
  Reviewed
  Role-played
  Social Skills Practice
  Suggested
  Supported
  Teaching/Lecturing
  Urge