The Importance of Case Notes
Case notes document the client’s interactions with your service. When writing them, providers must always consider that these notes may be read by others, including the clients themselves, legal practitioners, or courts. It is the provider’s responsibility to be aware of relevant agency and government requirements.
The primary purpose of case notes, as with any client population, is to assist the client. However, they may also be subpoenaed by a court or accessed by clients.
Purposes of case notes:
Provide professional accountability by evidencing the services and support provided to clients.
Assist with treatment planning and progress review by recording interactions with clients.
Demonstrate appropriate duty of care and responses to risk.
Meet the requirements of the funding body.
Help jog provider’s memories.
Assist in client handover.
Case notes should be:
Empirical and reliable
Relevant and targeted
Legible and clear
Recorded promptly
Kept in chronological order
Consistent
Guidelines for writing case notes:
Record case notes as soon as possible after the session.
Type notes, or if handwritten, ensure they are legible.
Write general session information concisely, referencing important information elicited, patterns regarding presentation or content covered, and common themes.
Provide specific information about client risk, including risk to self and others, with an emphasis on risk management.
Ensure any handwritten corrections are legible (original information should still be readable), signed, and dated.
· The length of your case note will depend on the purpose and content of the session. Providers should strive to keep their case notes concise. Source
Here is a link to a downloadable Progress Note template on my website. It is saved in word format so that you can edit the Support Worker Session/Progress Notes to align with your business.
Hope this has helped!
Jo
