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 (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

Note: Your client can request their file and read your casenotes!