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!
Last modified 5mo ago