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


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

Checklist for good quality case notes

Case notes should be:

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

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