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3.5 Case Notes Recording
Case records are the only record we have of the advice/information that has been given/received, and the actions that have been taken in relation to a client’s needs. If we have not recorded something, we cannot claim that we gave the advice, or took any action.
- We waste our client and the organization’s time, having to ask the same questions again.
- We may give wrong advice.
- We’re likely to miss giving useful advice or information as we don’t know all the relevant circumstances.
- If someone complains about us, we don’t have any evidence of what we’ve done and the advice we gave.
- It is difficult for others to follow on from the work that we have done if we share caseloads or work with volunteer advisors.
- If it happens, write it down - if you don’t it will become an invisible dog that may bite you at any moment!
- Write case notes as soon as possible
- Notes must give someone else a clear picture of the client’s situation
- Every interaction with the client or with a third party concerning the client must be recorded
- Make it clear who has responsibility for any actions.
Describe the issues/problem(s) that the client has presented
- Main issue/ questions/ circumstances presented by client.
- General assessment of client’s presentation (eg mental/physical health/ behaviour etc)
- Be certain to distinguish fact from opinion
- Options and consequences of them
Describe the task you had to complete to address the issues or problems presented.
Describe the Action that you took to address issues or problems presented
- Advice given
- Client’s decision(s)
- Action taken at the time
- Information given to client; referral /signposting details
- Follow up - include follow up actions and key dates when they need to be taken
Describe the results of your actions
- Easy to understand
- Avoid use of acronyms and if they are used what they mean is in brackets
- Include contact details for third parties when relevant
Note: Your client can request their file and read your casenotes!