Keeping files up-to-date

How do I ensure that the client’s file is complete and up-to-date?

In community and disability service organisations, client case notes, client assessment records, case plans and referral records need to be maintained and kept in accordance with organisational procedures and with consideration of confidentiality and the Freedom of Information Act.

Case notes

Notes may take a variety of forms, but generally they consist of a written record about events, statements or actions of some importance. One form of this is the ongoing file notes that workers have relating to their ongoing contact with their clients (sometimes called ‘case notes’). For example, a note may detail comments made by a client’s relative who has telephoned to explain a sudden change in behaviour. These notes are usually located in a specific section of the worker’s filing system and on the file of the client, and should be signed and dated by the support worker who wrote the notes.

Written reports

One of the most important sources of information for identifying clients’ needs is that of written records. These may include reports from:

  • client service workers in your own or other organisations
  • schools
  • courts
  • employers
  • health professionals, etc.

Often in work with young people within the child protection/juvenile justice context, a case plan exists. Up-to-date case plans are important in the process of finding out information about what support needs your client may have. If a family or individual has been to court or has had extensive work involvement in the past a case plan may be available. Sometimes case plans will not be available because assessments of risk and needs of the client are still being undertaken.

The client’s case plan

A case plan will give important information about a client. It should contain:

  • details of the family and family history
  • education
  • health
  • possible likes and dislikes.

The case plan will have been developed by people who have a detailed knowledge of the client, possibly a social worker; in many cases the client will have been involved as well.

A case plan may also contain strategies and ideas for meeting some of the immediate needs of the client. However, it is imperative that you are aware of the date of the case plan. If it is more that a few months old, the needs and situation of the client may well have changed quite dramatically, so it is important not to assume because it has been written down at some point that it is true of that person or their situation for evermore!

Sometimes a case plan will detail legal requirements, such as when your client needs to go to court if they are involved in the juvenile justice system. This information needs to be accurate and updated to ensure you are supporting the client to keep major requirements of orders.

Looking at a case plan will give you some ideas about what supports have been put in place, or need to be put in place for the client, and what resources are required to make sure the support happens.

Case example: The client's case plan

A three-year-old child needs to be linked in with the local preschool to learn how to play with other children of a similar age. This is recommended by the case plan and you have to look for the nearest childcare centre that they can go to.

A case plan also contains information about any special needs the client may have. It is important to get a clear picture of these needs. For example, a child or young person may have special needs if the client has a physical disability and needs a wheelchair at times, or may have special dietary requirements because of their cultural background. Issues such as these may impact on the types of support you introduce to the client.

In referring to case plans and other written information, it is important to be aware of the potential limitations.

The information may be:

  • out-of-date
  • inaccurate
  • no longer relevant as needs have changed.

A report on what a young person may have been like in a detention centre, for example, may suggest that a person has a specific range of abilities, and a list of areas where they need support. This picture may change significantly once they leave the centre, so you should clarify any assumptions in relation to needs identified from this source of information.

Correspondence and referrals

Official correspondence on a client’s file could include letters, memos, emails, handover notes, and referrals. These are all essential parts of clients’ files that are important for effective client service delivery.

Details that could be contained in these could include:

  • details of services or organisations
  • worker’s or other professional’s details
  • specific information about the client
  • dates of interviews, meetings, etc.

In some organisations written handovers occur at the end of one support worker’s shift when another is about to take over. In a handover, the initial support worker needs to provide the new support worker with access to relevant information about the client. This may include a short but detailed written report about the client’s current situation, including behaviour changes, incidents that have occurred during the shift, health needs, etc. Alternatively, the handover may be a summary and explanation about where to access other information considered important for the client.

Many of the records listed above, especially those that relate to detailed information about clients, are official documents. That is, they provide a record of what was done with and on behalf of a client, and they can be subpoenaed for use in legal action involving that client at any time in the future.

In some instances a client, or their legal representative, is also entitled to access aspects of these records under the Freedom of Information Act. For this reason, it is a legal requirement that these records are accurate and must be kept forever by organisations.

Keeping the client’s file complete and up-to-date

The only way workers can keep a client’s files complete and up-to-date is to make it a priority in their administrative tasks and set time aside in their busy schedule (weekly at a minimum) to file information and change records (e.g. dates, times and venues of interviews and meetings for the client) as required.

Last modified: Monday, 14 October 2013, 12:21 PM