Documentation Basics: A Fictional Case-Note Exercise

For this documentation exercise, separate four things: what the person reported, what you observed, what happened in the meeting, and any next step you both actually agreed to. Leave out unsupported additions. This is one practice habit, not a complete account of documentation requirements. The guide is for counseling and social work students working with a wholly fictional encounter. It gives you the source facts, a short illustrative note, and a printable exercise.

Before writing real records, confirm your site's format, required content, review process, and approved systems with your supervisor, including how applicable legal and ethical requirements are addressed. This guide teaches a habit, not a template.

Never practice with real notes in AI tools

Say it plainly: do not paste real case notes, real client details, or "lightly changed" real cases into SeatTime, a chatbot, or any other AI tool, including to practice wording. Do not practice on real records outside the systems your site approves.

The ethics codes do not name specific apps, but their privacy standards point the same way. The NASW Code of Ethics, standard 3.04(c), asks social workers to protect client privacy in documentation to the extent possible and appropriate. The ACA (2014) Code of Ethics, standard B.6.b, says counselors ensure that records in any medium are secure and that only authorized persons have access to them. ACA has announced a revision of its code, so check the current version on the ACA ethics page. For practice, use invented material only.

The fictional encounter

Everything below is invented. It adapts the conversation in our social work client interviewing practice guide, with additional facts for this exercise. Use the list below as your source, rather than treating it as a transcript of that guide. If something is not on this list, do not assume it happened.

• Setting: a made-up neighborhood community center. Tuesday morning, walk-in, about 20 minutes.
• Who: Sam, an MSW student intern supervised by a field instructor, met with Dana Mercer, an adult who came in on her own.
• Sam explained: Sam's role as a student intern, that Sam cannot decide whether anyone qualifies for a program, and the site's information about privacy, using the site's standard wording.
• Dana said: her work shifts were cut last month and now change from week to week.
• Dana said: her rent is covered this month.
• Dana said: she is worried about bus fare and groceries near the end of the month.
• Dana said: coming in "felt a bit embarrassing" and she is "used to handling things myself."
• Dana asked: "Will I qualify for anything?" Sam said that question is answered by Lee, the resource coordinator.
• Sam summarized and included rent as a concern. Dana corrected this: rent is fine; her concern is bus fare and groceries.
• Sam observed: Dana brought a folder of papers that stayed closed on her lap. She checked her phone twice. She laughed briefly when she said she felt embarrassed.
• Agreed: Sam will pass this question to Lee today: "With my shifts changing every week, what could I look into here for bus fare and groceries, and what should I bring?" Dana asked Sam to include her preference for Tuesday.
• Dana's preferences: contact by text, not calls, because she cannot answer calls at work. Tuesday and Thursday mornings work for her. She would rather go through paper forms with a person than fill them out on a phone.
• Not agreed or not discussed: no appointment was booked. Dana did not agree to apply for anything. Health, safety, household members, and income amounts were not discussed.

A short illustrative note

The note below is a fictional classroom exercise. It is not a clinical record, not a template, and not an example of any site's required format. It shows one way to write only what the facts support.

FICTIONAL CLASSROOM EXERCISE. Walk-in meeting, about 20 minutes, between student intern and Dana Mercer. Intern explained the intern role, that eligibility questions are answered by the resource coordinator, and the site's privacy information. Ms. Mercer reported that her work shifts were reduced last month and now vary week to week. She reported that rent is covered this month and that she is concerned about bus fare and groceries near the end of the month. Agreed next step: intern will give the resource coordinator Ms. Mercer's question today ("With my shifts changing every week, what could I look into here for bus fare and groceries, and what should I bring?"). Ms. Mercer asked to be contacted by text, said Tuesday and Thursday mornings work, and requested Tuesday if a meeting is arranged. She prefers reviewing paper forms with a person. No appointment was scheduled.

Where each statement came from

For this handoff exercise, the note leaves out the closed folder, phone checks, laugh, and embarrassment; none is needed to convey the agreed question or communication preferences. Another documentation purpose could call for different information. It does not turn those observations into a finding of anxiety. The NASW Code, standard 3.04(c), limits record content to information relevant to services.

Revising unsupported phrases

Each phrase below is the kind of thing that slips into a first draft. None of it is supported by the facts above.

The point is not that inferences are forbidden everywhere. Clinical judgment exists, and your site may ask for it in a specific section and format. The point is that a student practicing basics should be able to trace every sentence back to something reported, observed, done, or agreed, and should not add observations or findings that the encounter does not contain.

Printable exercise: source fact, draft sentence, inference to remove

Print this table or copy it into your notebook. The first rows are filled in. Complete the rest using only the facts in the fictional encounter.

Redo prompt: change one fact and rewrite only the sentences it affects. Suggested change: at the end of the meeting, Dana says, "Actually, don't send anything to Lee yet. I want to think about it and I'll come back Thursday." Rewrite the agreed next step without adding a reason she did not give, then check whether any other sentence in the note now needs to change.

A learning reflection is not a client record

Students write two kinds of documents about the same meeting, and they serve different purposes.

A learning reflection is for you, your instructor, and supervision. It can include what you noticed about your own wording, the moment you assumed rent was the worry, what you would try differently, and how the meeting felt. Its audience is your learning.

A client record exists for accuracy and continuity of services. The NASW Code, standards 3.04(a) and (b), asks social workers to keep documentation accurate, to reflect the services provided, and to include sufficient and timely documentation to support delivery and continuity of services. ACA (2014) standard A.1.b describes counselors maintaining documentation necessary for professional services, keeping it sufficient and timely, making sure it accurately reflects client progress and services provided, and properly noting amendments according to agency or institutional policies.

Do not treat permission from a program as sufficient authorization to share client material. Confirm the applicable consent, confidentiality, site, and course requirements with your supervisor before preparing a real-case assignment. ACA (2014) F.5.c requires students and supervisees to obtain client permission before using information about the counseling relationship in training. B.6.d separately addresses permission for observation and review of session transcripts or recordings. Use invented material for this exercise. For record retention, follow the requirements identified by your site; NASW 3.04(d) refers to laws, agency policies, and contracts.

Questions to ask your instructor or site

Before you write a real note, get answers to these:

1. Which template or format does this site use, and is there an approved example I can look at?
2. What content is required, and what should stay out of the record?
3. Who reviews my notes, and when do they need to be finished?
4. Which systems and devices am I allowed to use for client information?
5. How are corrections or amendments made after a note is finished?
6. What consent, confidentiality, and site requirements apply to placement material used in class, and who confirms that they are met?
7. If something was not discussed, does the site expect me to say so, and in what words?

Where SeatTime fits

SeatTime is a text-only tool for rehearsing conversations with fictional AI clients, built for adult learners: graduate students and early-career practitioners. It does not write or review case notes. After you type a conversation, you read AI-generated feedback on what you said, which can be wrong. It's optional practice outside your program and doesn't count toward any program, placement, or licensing requirement. Keep real client information out of it entirely, and bring documentation questions to your instructor or supervisor. Rehearse a conversation with a fictional AI client, or read how SeatTime practice works.

Sources

• National Association of Social Workers (2021), Code of Ethics: Social Workers' Ethical Responsibilities in Practice Settings — official text; standard 3.04(a) to (d) on accuracy, sufficient and timely documentation, privacy and relevance, and retention set by laws, agency policies, and contracts.
• American Counseling Association (2014), ACA Code of Ethics — official PDF; standards A.1.b (records and documentation), B.6.b (security and authorized access), B.6.d (permission before others observe or review sessions in a training environment), and F.5.c (client permission before using counseling-relationship information in training).
• American Counseling Association, Ethics resources page — official page; confirms the 2014 code remains current while a revision is underway. Check here for the current version.

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