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A huge part of the Human Service profession is being able to write good case notes. Being able to document your encounters with your clients ethically is key to being a competent Humans Service Professional. Read the following case note written by counselor. Your job is to carefully examine the case note for ethical errors and identify what type of ethical errors they are. Good Luck
Client Name: Sarah J.
Date of Session: October 22, 2024
Session Summary:
Sarah came in for her third session today, though she seemed uninterested and didn’t have anything new to talk about, so the session was not productive. I don’t think Sarah takes her therapy seriously, and it feels like she’s just wasting time. She was late again and blamed her “chaotic life,” which doesn’t seem like a valid excuse.
Sarah insists that her marriage problems are her husband’s fault, but it’s clear she’s in denial about her own bad attitude. She mentioned that her husband thinks she’s controlling and needy, and I think he has a point. Sarah talks excessively about wanting “happiness” and “peace,” but it’s obvious she just wants attention and doesn’t actually plan to make changes.
Sarah has previously mentioned alcohol use, and I suspect she may have an alcohol problem, even though she denies it. I plan to work with her on this issue next session, whether she likes it or not. Overall, Sarah presents as a difficult and non-compliant client who is not making progress in therapy.
Task:
1. Identify Ethical Errors
Copy and paste the case note.
Identify the ethical errors by either underlining or highlighting at least 10 specific ethical errors in the case note above. Consider issues related to:
Judgmental or pathologizing language
Confidentiality breaches
Bias or lack of objectivity
Unsubstantiated assumptions or diagnostic labels
Lack of clarity or factual basis
2.Rewrite the Case Note
Rewrite the case note to correct the ethical errors you identified. Use clear, objective, and respectful language. Document observable behaviors and avoid any speculative or judgmental language. Reframe the note to focus on Sarah’s presenting issues and progress toward her stated goals.
3.Reflection
Reflect on the ethical implications of documentation in human services. Answer the following questions:
Why is it important to use objective and non-judgmental language in case documentation?
How can unprofessional language in case notes impact a client if the notes are shared with other professionals or in a court setting?
What steps can you take to ensure ethical documentation practices in your own work?
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