As a health worker or a youth worker you are normally required to keep case notes. A young person should be told that case notes and other records will be kept about them and they should be able to access them on request.

Tasks
Overhead transparency
Examples of case notes
Improving case notes and records
Writing for other organisations
Referral letters

Tasks

Brainstorm exercise

Question - Why do you think we keep case notes?

Answer
  • Accountability (so that we can demonstrate we are providing an appropriate and effective service)
  • Legal responsibility (case records can be subpoenaed as court documents)
  • To keep a history of the client (so that we can provide appropriate therapy/care)
  • To make referrals to other agencies.

Writing exercise

Question - What sort of information do you keep in your case notes?

Overhead transparency

Most case notes contain the same general information, which includes:
  • the personal details of the client (these are on a referral sheet/cover sheet)
  • family history
  • type of contact (whether you phoned the client or saw them at home, at a centre or in a formal counselling situation?)
  • details of major issues
  • action plans (detailing who is responsible for which action)
  • arrangements for the next meeting.
Top of page

Examples of case notes

Learners should read these examples in their Learner's Workbook.

Example 1. 20/10/02 – Accommodation service

Client interviewed for first time in the Office. Was referred from local child protection agency. Seemed very angry and hostile at the beginning of the interview, but seemed more settled once I had indicated that her involvement with the agency was to be on a voluntary basis only, and that she could choose to leave whenever she wanted. Seems to have had a number of involvements with agencies over the years, some of which she seemed OK about, some of which seems to have acted as a negative reinforcement. Stated that she feels that everyone else seems to be in control of her life except her. Parents and boyfriend have been 'giving her grief' about her using.

Client stated that cocaine is her current drug of choice and that her use is limited to weekends because of financial restraints. Stated that weekends are 'fairly heavy' and that she is struggling to get through the week. Outlined policy regarding AOD use on these premises. Client told that she would have to leave the program if she uses on the premises. She agreed to come back next Friday at 2 p.m. to discuss the issues in more detail and whether she wants to commit to this program.

Example 2. 20/10/02 – Outreach service

Phoned client to check how things were going in relation to problems with transport to visit various specialists at the local hospital. Client said that family is unable to assist. Said that I had been in contact with local community transport group who are happy to assist. However, client will need to contact them to make the arrangements and provide details of dates and times. Client indicated that this was fine and that he would get in touch with them in the next few days. Indicated that I would see him next week as arranged.

Task

Question - Do you think that these case notes are useful? If not, why not?

Improving case notes and records

Task - writing exercise

Question - Consider the case notes you are currently writing. Would they be useful to another case worker if you were to leave the organisation? Do they give an accurate picture of the client's history and current situation?

Question - Can you think of ways in which you could write better case notes than the ones you are currently writing? Consult the following checklist in your Learner's Workbook see where you can improve.
  • Do you always use language that is nonjudgemental (i.e. neutral)?
  • Do you avoid making assumptions about the client and always stick to the facts?
  • Do you always indicate clearly when a comment is an observation (e.g. she seemed upset)?
  • Do you make it clear when you are recording the client's own words (by using quotation marks or by writing 'the client stated that...')?
The courts can subpoena records and other reports and you need to be very careful about what you say about a client. Take care to record only what you have observed about a client.

You can also be subpoenaed by the court to explain your case notes. Since you need to be able to justify every entry in your case records, ensure that your notes are not ambiguous in any way. You can ensure this by only recording observations and relevant statements made by you or the client.

Write your case notes as soon as possible after you have seen or spoken with a client.

Clients have the right to access their records so they should always be written as accurately and clearly as possible.

Question - Are there any guidelines in your policy and procedure manual regarding critical incidents? How are these reports filed at your organisation? Are they kept in a secure place? Top of page

Writing for other organisations

Workers are often required to send reports or letters of referral to other agencies. This information needs to be presented in a way that is:
  • clear
  • concise
  • accurate
  • reliable
  • relevant to the request
  • presented appropriately.

Referral letters

Task

Read the following referral letter and underline the places where the worker has used inappropriate language.

Example: Referral letter

Sunnyvale Rehab Centre

Tuesday

Dear Jimbo,

Ben is one of my clients and he's asked me to see if he can come into your program sometime soon. He is very immature and has poor social skills. I think that his parents are to blame for this as they moved around a lot when he was young.

Ben comes to our centre quite a lot and he told me that he fancies Mary, one of our other young clients. I don't think she fancies him. He is always off his face when he arrives and usually causes fights by punching and hitting the other boys.

I don't think that he would fit in very well at your service, so I would think twice before accepting him into your residential program.

Call me if you want more info.

Cheers

Fred Nerk

p.s. Fred has three younger sisters living at home. Top of page

Task - writing exercise

Write your own version of this letter, using appropriate language.