Goal Setting, Action Plans, and Case Notes
Throughout the client session, your aim should be to get a clear understanding of the client’s goals and create an action plan based on their needs. Adhere to the policy and mandate of the agency you are working within. A strong connection exists between a client’s objectives, steps taken, and written records. During client meetings, the main aim should be to fully understand their needs in order to establish their next steps.
Setting specific goals and creating a plan of action is crucial, as is ensuring these aims are in line with the agency’s policies and the client’s preferences. Person-centred planning principles are helpful for these steps. Bailey (2017) emphasized the importance of SMART goal setting for healthy behaviour change. The article suggested that strategies like self-monitoring, social support, problem-solving, and skills training are highly important in successful goal setting. Goals should be approach-based, challenging, and intrinsically motivating. Action plans refer to the outline of steps for achieving goals, such as providing immediate feedback. Prioritizing goal setting and action planning benefits both practitioners and clients. Community support workers can assist clients in healthy behaviour change by setting goals and creating action plans.
Although the intentions of goal setting and action plans are clear and important, the process might face some obstacles. There may be cases where clients are unsure of what they want or need, and that may hinder the goal setting process. Throughout the discussion with the client, you may provide assistance for clients to clarify their wants or needs through reframing, summarizing, and paraphrasing what you hear them say.
Another setback that may arise is a client’s resistance to change. Resistance to change is very common, and occurs for many reasons, such as our nervous system and the drive to stay in what is known. Even if what is known is not working for us, it feels safe. Some resistance to change comes from trauma and fear of the unknown.
Some other barriers may be high levels of stress, lack of a support system, feeling overwhelmed, feelings of discomfort, and uncomfortable thoughts. Not being able to imagine something different also makes change more difficult. Some behaviours that may indicate a client is resisting change are cancelling appointments, being late, avoiding conversations, changing the subject, making excuses, justifying the unhelpful behaviours of themself or others, blaming others for not changing, romanticizing habits that are necessary to change, procrastination, and acting in a passive-aggressive way.
Activity
Reflection questions:
- How would you support a client who is resisting change?
- What questions might you ask them to support a change they wish to achieve?
- What are some reframing phrases you could use with a client to work through resistance to change?
The secret of change is to focus all of your energy not on fighting the old, but on building the new.
–Socrates
Anticipating some form of resistance to change is a normal part of the process, and developing ways to explore this resistance with clients will be a useful part of the goal setting process. A client will typically come to the agency because they are seeking change. Despite wanting this service, they may be unsure of what the outcome will be. Based on the goals in the action plan, outlining a step-by-step process of what will happen, imagining possible outcomes, and seeking client input and ideas throughout will make the action plan more successful.
Part of the process is goal setting. SMART goals offer a helpful framework for goal-setting. According to Bell (n.d.), SMART goals are useful to “clarify your ideas, focus your efforts, use your time and resources productively, and increase your chances of achieving what you want in life.”
SMART is an acronym for specific, measurable, achievable, realistic, and timely. One goal should be set at a time, and each of these steps should be considered in order to achieve the goal. With a client, you will likely set a long-term goal (6 months) and a short-term goal (2–3 weeks). Each goal should be written out separately and follow-up should occur as per the timeline, to support the client in achieving the goal. During this process, you may notice resistance. With active listening, exploration, and reframing, you can assist the client to work through the resistance to change, and ultimately achieve their goals.
Throughout the CSW and client interactions, documentation must take place as required. One category of documentation is case notes, which should be taken in each client session and be kept on the client file. Writing down the key points of a client appointment will assist you in tracking the client’s progress, understanding the effectiveness of your approach to helping, and knowing if the goals were reached.
When documenting a client’s file, there are specific requirements for taking case notes. Each agency will have its own policy to be aware of. When creating the record, consider the following:
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- Answering the five Ws: Who? What? Where? When? And why?
- Steps taken to reach decisions, including observations
- Include specific types of information such as evaluations, assessments, referrals, and action plans
- Distinguish between fact and opinion. For example, in my professional opinion…
- All notes should adhere to the agency’s code of ethics
Another consideration is when to write the case notes. Writing case notes during the session may be ideal, so we remember everything accurately, however writing while the client is speaking may lead to unintended consequences. They may feel we are ignoring them or not paying attention, and we may miss important nonverbal cues. The following are some examples of certain times when you should not take notes:
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- There is an emergency situation
- You are still trying to build trust and rapport
- During the getting to know you phase with client
- The client sharing a highly emotional subject
- The client seems uneasy about what the worker is writing
- Any other ideas?
Lastly, the client must be informed about their file and what is being written. The client has the right to read what you write and to access their file at any time. If the file is to be shared, the client must be informed. As a worker, you must also inform the client of the duty to report under certain circumstances, such as if they pose a risk of harm to themself or others. Case notes should be written with the understanding that what is on the record may be subpoenaed to court. The case notes should only include information pertinent to the services being provided, and confidentiality should be explained to the client. All of the above components are part of the middle stages of working with a client. Concluding a meeting or client file also has a predetermined process to be followed.
References
Bailey, R. R. (2017). Goal setting and action planning for health behavior change. American Journal of Lifestyle Medicine, 13(6), 615–618. https://doi.org/10.1177/1559827617729634
Bell, S. (n.d.). SMART goals. MindTools. https://www.mindtools.com/a4wo118/smart-goals
Image Credit
Figure 3: SMART goals by Mikel Agirregabiria, CC BY-NC-SA 2.0.
