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!