Case notes

Many organizations keep notes on a specialized kind of data-base or use forms especially designed for the purpose. If you find weaknesses in formats, give your suggestions for improvements in your staff meeting. The guidelines below will help you decide what to put in case notes and what to leave out.

  1. Keep each clients' case notes separately filed. Clients have a right to view their own case-notes, but may not view those of other clients.
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  2. Keep enough notes to enable someone else to take over your caseload at any time.
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  3. Case notes are confidential, so you can include details that will not be revealed to people who don't have a right to know.
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  4. You may have to be blunt to be clear. Don't be vague and indirect about a problem to avoid an unpleasant truth; you don't want a replacement case manager to misunderstand your notes.
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  5. Stick to factual information.
    1. Keep an "objective" tone.
    2. You can include straightforward reports of events and direct quotes from the client.
    3. Include decisions of what needs to be done, who will do each task, and when they should have it done by.
    4. Include details of referrals.
    5. Include diagnoses and your reasons for them.
     
  6. Include things that may be important later on. You don't want to appear negligent in the future for missing something that turned out to be important. e.g.
    1. You may also include options for diagnoses that you have ruled out and the reasons for doing so.
    2. You can include avenues of action that you must consider. If you have reason to suspect something may be a problem and needs checking, you should write it down and make a decision to check or monitor it.
     
  7. Do not include:
    1. Anything that you wouldn't want the client to read (e.g. anything that would be seen to be derogatory of the patient.) Under privacy law, clients have a right to view their own files if they wish and can sue you if the notes are evidence of irresponsible treatment.
    2. Your personal impressions or hunches. If you can't confirm them with some kind of evidence, don't put them in.
    3. Deliberations that lead up to diagnoses or treatment decisions. These generally contain lots of unproven "perhaps" things that would be distressing for the client to read.
    4. Bureaucratic gobbledygook just to keep the office happy.

Sometimes you still won't know whether to put something into your notes or leave it out, and perhaps it could go either way. Discuss it with your supervisor or in a staff meeting. You might find good reasons for doing one or the other.

Case notes for unusual cases

You will occasionally have cases where you need to keep detailed observation records of bizarre behaviors because you might need them one day.

A hyperactive eight year old child exhibited antisocial behavior to other students. He could not be left unsupervised, even for very short periods. For example, if he sharpened a pencil, he would test the point on a classmate. If the person didn't bleed, he sharpened it and tested it again until they did.

For administrative reasons, the child could not simply be expelled, and there was no psychologist to whom the teacher could refer the child. A suitable solution would require some hard evidence.

Consequently, the supervisor was advised to keep a detailed, contemporaneous diary of incidents so the Principal could take action.