Writing case notes
All workers are required to keep some record of their contact with clients. The records you keep will vary according to your role and responsibilities. They may include:
- completing a communication diary
- writing case notes in the file
- filling out incident reports
- writing formal reports for supervisors or courts.
Each of these case records is an important form of communication and must meet the required organisational standards.
A common responsibility for communities and disability services workers is to record the information and planning agreed to in client interviews and meetings. This should be done shortly after an interview or meeting with a client has been completed. For what is considered 'usual' patterns of behaviour, provide only brief notes. Greater detail should be included about events or incidences that are deviations from the person's usual patterns of behaviour. This includes positive deviations (for example, he was more talkative than usual) and negative deviations (for example, she was shouting and shaking her fist).
Some records, such as case plans and incident reports, are legal documents and can be used in formal proceedings such as courts or grievance processes. It is vital that these are accurate and well written.
Guidelines for written records
To write case notes, records of interviews and reports:
- Write it up as soon as possible.
- Record the date, time, location and names of those present for the interview.
- Record the source of information (who said what). Use inverted commas to indicate direct quotes.
- Aim for accurate and objective reporting – avoid bias and judgement.
- Record facts rather than your opinions. Where interpretations are unavoidable, make it clear that the information is a personal interpretation, e.g. ‘It has been my observation that.’
- Record behaviours – what the person actually did, their actions or expressions.
- Distinguish between facts and inference – what actually happened, not what you thought might have happened.
- Record the reasons why you made a decision.
- Omit any information that is unrelated to case management.
When you are writing your notes:
- Be concise. Use short sentences and paragraphs.
- Use plain, everyday language.
- Use active verbs rather than passive verbs. 'John drove the car' (active) is preferable to 'The car was driven by John' (passive).
- Set out information clearly, using appropriate headings.
- Check for misspelled words and inaccurate or unclear statements.
You should ensure that all case notes, records of interviews and reports you write are dated and signed and meet all other organisational requirements.