# 3.5 Case Notes Recording

### **Case recording - why do it?**

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.

#### **If we do not case record properly:**

* 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. 

### **Case recording - how to do it**

#### **Basic rules:**

* 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. 
* We recommend using the [STAR](https://en.wikipedia.org/wiki/Situation,_task,_action,_result) (Wiki) method when writing up your notes STAR stands for: 
  * S-Situation
  * T-Task
  * A-Action 
  * R-Result

### What to record

#### **Situation:**

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

#### **Task:**

Describe the task you had to complete to address the issues or problems presented.

#### **Action**:

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

#### **Result:**

Describe the results of your actions

### **Checklist for good quality case notes** 

#### **Case notes should be:**

* [ ] Legible
* [ ] Brief
* [ ] Relevant
* [ ] Easy to understand
* [ ] Non-judgemental
* [ ] Avoid use of acronyms and if they are used what they mean is in brackets
* [ ] Include contact details for third parties when relevant

{% hint style="warning" %}
**Note:** Your client can request their file and read your casenotes!
{% endhint %}