3.5 Case Notes Recording
Last updated
Last updated
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.
We recommend using the (Wiki) method when writing up your notes STAR stands for:
S-Situation
T-Task
A-Action
R-Result
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
Note: Your client can request their file and read your casenotes!