Case Notes

Case notes provide a record of the client’s interaction with your service, and in writing them it is important that practitioners are always mindful that they may be read by others (whether the clients themselves, or by legal practitioners and courts. It is the clinician’s responsibility to be aware of relevant agency and government requirements.

As with other client populations, the ultimate purpose of case notes is to assist the client. However, case notes may be subpoenaed by a Court or accessed by the clients themselves (i.e. through Freedom of Information Act requests). Case notes should always be written as though this will happen, not might happen.

Case notes serve many purposes:

  • Provide professional accountability by providing evidence of services and support being provided to clients;
  • Assist with treatment planning and progress review by providing a record of interactions with clients;
  • Demonstrate appropriate duty of care and responses to risk;
  • Meet the requirement of the funding body;
  • Help jog clinicians’ memories;
  • Assist in client handover.

Case note criteria:

  1. Empirical and reliable
  2. Relevant and targeted
  3. Legible and clear
  4. Recorded promptly
  5. Kept in a chronological order
  6. Consistent within the organisation.

Case note guidelines:

  • Include only information relevant to service being provided and do not omit information that is relevant
  • Report facts and observations / interpretations that have supporting evidence (“the client appeared anxious as demonstrated by…”)
  • Avoid biased language, emotional language, value judgments, opinions and street language / jargon (unless quoting the client)
  • Acknowledge source of information (“The client reported that …”)
  • Avoid using other people’s names in your case notes (use wife, partner, brother etc. or first names only)
  • If unsure about whether to include something in your case notes, seek guidance and advice from your supervisor

Adherence to these guidelines will provide protection should your case notes be subpoenaed.

What to include in case notes:

  • Session details: date, time, client’s name, session number/type
  • Description of client presentation based on brief MSE (highlight deviations from usual for existing clients)
  • Session content:
  • Disclosure of ethical obligations / confidentiality
  • Main themes discussed
  • Interventions used
  • Progress and future goals
  • Plan for next session
  • Record any risk factors including detailed record of actions taken in response to risk

Writing up case notes:

  • Record case notes as soon as possible after the session / event
  • Type notes, or if handwritten, ensure they are legible
  • General session information should be written in a concise manner with reference to important information elicited, patterns regarding presentation or content covered, and common themes
  • Specific information should be provided when covering information about client risk, including risk to self and others. Emphasis should be placed on the management of risks when case noting.
  • If a change is required, best practice is to record the change as a new case note, including an explanation of the error or omission in previous case note (do not alter the original case note)
  • If new information comes to light after the session, it should always be included in a new case note, not added to the original case note
  • NEVER use white-out on a case note. Ensure any hand-written corrections are legible (original information should still be readable), signed and dated
  • The length of your case note will be dependent on the purpose and content of the session undertaken. Clinicians should endeavor to keep their case notes succinct.

Freedom of Information

The Victorian Freedom of Information Act 1982 gives clients the right to request documents held by the Department of Justice and Regulation or the Department of Health and Human Services, and allows for incorrect or misleading information held by the departments to be amended or removed.

FOI requests are usually received from current clients, from lawyers when clients receive new charges, or when clients are released on parole.

In most cases, the document MUST be provided. You can argue to restrict release, or redact aspects of the document, only if their release will pose a significant safety risk to the client or others.

FOI requests are becoming more common – therefore you should always keep this in mind in everything that is documented in a client file (including case notes, reports, assessments, etc.)

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