Description
The purpose of this task is for students to demonstrate engagement, interview and assessment skills for practice with individuals.
Unformatted Attachment Preview
Case Studies for Assessment 2
MSWPG7102 Professional Social Work Practice
1. You are a youth worker who has been just assigned to a new case. The person you
are meeting is 16 year-old young person, Ari, who is not engaged with school and
lives with their friends. Ari was referred to your agency by the police for some minor
offences and for being at risk of becoming homeless.
You meet Ari at the agency and find them to be friendly and easy to engage. Ari
knows the Police are keeping an eye on them, but does not think it is anything
serious because the Police said all they need to do is talk to a social worker (you).
Ari has no interest in school or TAFE, education isn’t important right now. Ari dreams
of becoming a famous actor and trying to figure out how to get noticed by the film
industry through social media.
Ari has no contact with their parents since leaving home and says that their parents
never really cared for them. Ari is interested in your agency and what support they
can offer, they don’t see any problem or risks with their life.
2. You are a social worker at a Community Support Agency working with a young
woman, Sami. Sami is married to her partner, Raj. Sami and Raj have both recently
lost their jobs due to the COVID-19-related businesses shut down. They migrated to
Australia recently and are unaware of what kind of support they may be eligible for.
Raj feels that it is not appropriate for them to apply for financial aid or support
because they are both young, healthy and have a good education. He feels that
welfare or crisis payments should be only for people who are sick or who have a
disability and can’t work.
This new situation is causing a lot of stress for Sami and Raj and their relationship.
They have started to argue and cannot agree on anything. Being recent arrivals to
the country, they have no family support in the country and no close friends. Sami
has come to your agency to see what support you can offer.
3. You are a new social worker with a primary-school wellbeing team. One of the
teachers refers to you for counselling a 12 year old girl, Ana. She has always been a
quiet student but lately her teacher has noted that she is not talking to any of her
classmates, spends most of her free time by herself and eating lunch alone.
The student has been an average student but lately she stopped doing her
homework projects or just brings in her work half-way done. During your first meeting
she tells you that there is nothing much going on in her life. She also says she does
not see a point in making friends or doing her work because she will be leaving this
school in couple months.
Ana is feeling upset with her parents for making family decisions without her input.
They told her last year that this will be her primary school until she graduates and
goes onto high-school in town, but now they are moving her again to another state.
She believes her parents do not care what she wants or needs and only care for their
jobs.
4. You are a new social worker at an Emergency Relief Agency in a small regional
town. A 72 year–old man, Ted, who is a pensioner and lives in nearby public
housing, comes to see you. He is having some difficulty remembering why he has
come.
Ted has no family, very few supports in his life and likes to keep to himself. He is ill
and frail, has no money and worries a lot about what will happen to him.
While Ted has been experiencing increasing challenges with his health over recent
years, previously he always enjoyed a high degree of independence and control over
his own life. He liked helping others, but was never one to ask for help.
This is changing now however. Recently Ted lost his car licence due to a medical
condition, This has increased his feelings of isolation and sadness and fear of
dependency. Sometimes, he drives his car around town anyway.
Ted is very clear with you that he wants his food voucher, but he’s also wondering
quietly if you might be able to help him in other ways too.
Role-play tips:
“The client”: Your role is to make it easy (but not TOO easy) for the “social worker” to
practice their skills. You are not supposed to be “the most challenging client ever” (overly
resistant/distrustful; highly complex issues; overly emotional), auditioning for a dramatic
acting award, or “the rescuer” (trying to help the social worker by giving them too much
information too early, or prematurely solving your own problems).
You will be given “cues” about your situation and presenting behaviours. Please use them.
You are playing a role – not delving into your own issues/experience. If the circumstances on
the cue sheet are similar to your own, you might not want to take on the role or, ensure that
you stay in role.
“The social worker”: Your role is to practice specific skills using the role-play.
Assessment 2: Recorded practice skills role-play and CASENOTE
Information about Recorded practice-skills role-play
Recorded practice-skills role-play and Casenote
• Length: 20 minutes maximum
• Format: Video
• Due date: TBC
• 35% of total course mark
Submission instructions – Assessment to be submitted to Moodle via link as either:
– A Kaltura link to a video recorded role-play, if you meet in person with your partner
– A Microsoft Teams recorded role-play, post the link to the recording on Moodle
Further instructions on how to record and upload role-plays are provided in Moodle.
Task Description
The purpose of this task is for students to demonstrate engagement, interview and
assessment skills for practice with individuals.
Students will be provided with a range of role-play case-studies on Moodle, and record
a role-play of themselves as a social worker role engaging and interviewing a client.
The client role can be undertaken by anyone who is available and content to play the
role – a student, friend or family member.
Students will be assessed on their capacity to display a range of engagement, interview
and assessment skills. Students can choose to engage with their ‘client’ via face-toface, telehealth (video) or online (PLEASE DO NOT USE A PHONE interview as you will
not be able to fulfil all requirements), and demonstrate appropriate skills, such as:
•
•
•
•
•
•
•
•
•
•
•
•
•
Information giving – i.e. role and setting, how confidentiality is addressed,
informed consent
Rapport building and attending behaviours (including appropriate introduction)
Engagement skills
Active listening
Reflective listening
Picking up on verbal and non-verbal cues.
Appropriate use of questions (closed-ended and open-ended)
Paraphrasing
Reflection of client’s feelings
Summarisation (beginning, throughout, and at the end)
Clarification
Interpretation
Closure/ending of interview
Following your recording please write a case note of no more than 200 words
relating to your scenario.
the CASENOTE needs to be included with your submission.
Role Play – Tips and Tricks for MSWPG7102
Role plays will be a key focus of this course, to provide students with opportunities to
develop their social work direct practice skills. Given the number of students enrolled
in the course, it is important that role plays run smoothly and to time. Otherwise,
students will get frustrated over the amount of time wasted and will miss out on
valuable opportunity for skill development (which is the main focus of this course).
These guidelines have been developed to ensure that all students are clear on
expectations about role plays.
Assigned Role Play Groups
Students will be form “role play groups” at the first seminar. During role plays,
students will rotate the following roles: (1) “social worker;” (2) “client;” (3) observer
and time keeper; (4) observer and time keeper. In the instance of a group with five
people, there would be one extra observer/time keeper. In the instance of a group
member being absent, there will be one observer/time keeper. If two group members
are absent, staff will reconfigure accordingly for the seminar in question.
We ask that you be open to working with a variety of students, as this will be a more
true representation of ‘real world’ social work practice.
Any students who have concerns about the behaviour of a group member should raise
it with that group member (if they feel comfortable doing so). If this is not appropriate,
or does not address the concerning behaviour, then the student should approach staff.
Expectations/Etiquette of Group Members
It is important that all students are mindful of how they interact within their group.
Below are some expectations to help guide you:
1. Keep to time. Each role play activity will have an allocated time, for example:
getting in to role (3 minutes); role play (5-15 minutes); getting out of role (2
minutes); feedback (5 minutes). It is important that everyone stays on time, or
else some students will miss out on the opportunity to play the “social worker”
for each skill set.
2. Remember the role of each “player”
3. “The client”: Your role is to make it easy (but not TOO easy) for the “social
worker” to practice their skills. You are not supposed to be “the most
challenging client ever” (overly resistant/distrustful; highly complex issues;
overly emotional), auditioning for a dramatic acting award, or “the rescuer”
(trying to help the social worker by giving them too much information too early,
or prematurely solving your own problems).
4. You will be given “cues” about your situation and presenting behaviours. Please
use them. You are playing a role – not delving into your own issues/experience. If
the circumstances on the cue sheet are similar to your own, you might switch
with another student, or, ensure that you stay in role.
5. “The social worker”: Your role is to practice the specific skills we are working on
with each progressive role play.
6. “Observer/time keeper:” Your role is to: ensure that everyone sticks to time (use a
timer on a phone and stick to it ruthlessly); make sure that the “social worker”
and “client” get in, and out, of role, and get your Group Leader if someone
becomes distressed or anxious. Your role is also to lead discussion about how
the role play went, and to provide feedback that is honest and respectful. While it
might be polite to say, “You did a fantastic job!” that won’t help students
improve. Identify areas of strength, but also areas for improvement. If students
digress (talking about their own personal experiences in relation to a scenario,
for example) your role is to gently get them back on track.
7. Confidentiality. Role play groups will need to develop a sense of trust. It is not
appropriate to discuss what happens in your role play group with other
students (i.e. if a student performed poorly or got upset) or friends, family,
colleagues.
8. Role plays can be stressful. While some students enjoy the challenge of role
plays, at times some students can find them stressful. They may feel
uncomfortable being observed and having other students provide feedback.
They may find that being in the “client” role “triggers” underlying issues. A
certain amount of anxiety is entirely normal. However, if you find that you are
consistently stressed/anxious and/or the experience gives you intense anxiety,
then you are advised to seek support from the Uni Counselling Services (or a
service of your choice). This is not a sign of weakness, but rather of your
capacity for self-reflection and self-awareness.
9. Practice makes perfect. Well, no social worker is ever perfect – but practice will
make you as perfect as possible! You are strongly encouraged to meet up with
other students (either on the “off” Fridays or at a time that suits a group) and
willing family/friends/colleagues and practice your skills. Using a phone, iPad or
tablet to record and watch yourself is a fantastic learning tool.
10. Have fun! (But not TOO much fun!).
Case Notes
Case Notes
Case notes are an integral and important part of practice for many Social Workers. Research has shown
that record- keeping practices have an impact on client outcomes such that poor case notes can result in
poor decision-making and adverse client outcomes (see Preston-Shoot 2003, Cumming et al. 2007).
A ‘case note’ is the term applied to a chronological record of interactions, observations and actions relating
to a particular client.
What information should be included in a case note?
The guiding principle for deciding what information should be included in a case note is whether it is
relevant to the service or support being provided.
The type of information that is considered relevant will clearly depend on the context of practice, however
the AASW Practice Standards 2013 provide some broad guidance. This may include:
•
a range of biopsychosocial, environmental and systemic factors impacting on the client. This
includes consideration of an individual’s culture, religion and spirituality
•
risk and resilience factors
•
facts, theory or research underpinning an assessment
•
a record of all discussions and interactions with the client and persons/services involved in the
provision of support including referral information, telephone and email correspondence
•
a record of non-attendance, either by the Social Worker or client, at scheduled and agreed
meetings or activities
•
evidence that the Social Worker and client have discussed their respective legal and ethical
responsibilities. This may include:
o
client rights, responsibilities and complaints processes
o
the parameters of the service and support being offered and agreed to
o
issues relating to informed consent, information sharing, confidentiality and privacy
o
efforts to promote and support client self-determination and autonomy
o
specific responsibilities to clients in particular settings such as private practice or rural
settings as per the Code of Ethics 2010
•
o
professional boundaries and how dual relationships may be managed
o
record keeping and freedom of information
o
discharge planning
o
relevant legislative requirements and their possible implications for practice
details of reasons and any related actions or outcomes leading up to or following the
termination or interruption of a service or support.
1
Ethics and Practice Guideline – Case Notes
Updated July 2016
How should this information be represented in a case note?
There are a number of case-writing models available to Social Workers. Some of them provide general
guidance for writing case notes, such as the ‘Summary Style’, while others are specific to a service type or
context, such as the STIPS model.
In addition, many organisations have policies and procedures around case recording.
The AASW does not recommend the use of one model or policy over any other, however the Code of
Ethics 2010 points to some general principles for good record keeping.
Information recorded about a client should be impartial, accurate and complete with care taken to ensure
that:
•
only details relevant to the provision of a support or service to which the client has consented are
•
when working with involuntary clients this means recording information relevant to statutory
recorded (see sections 5.2.5 (a) and 5.2.4 (b))
practice (see also 5.2.2)
•
notes are free from derogatory or emotive language (5.2.4 (a))
•
subjective opinions are qualified with relevant
•
background information, theory or research (5.2.5 (a))
•
relevant information is not omitted (5.2.5 (c)).
When recording information about third-parties, such as information about a client’s relationship with
significant others, it is equally important to separate fact from opinion.
For more information and for Social Workers in particular settings, such as Private Practice, please see
our related Ethical Guidelines on the AASW website at www.aasw.asn.au/whatwedo/ethics-faqs
How and when should case notes be recorded?
Case notes can be recorded manually or electronically and should:
•
include on each page the name and DOB or other identifying information of the client. This can
be handwritten, typed or constitute an electronic tag where an electronic case recording program
is utilised
•
be dated
•
be recorded as soon as possible after an interaction or event
•
be typed or clearly readable if handwritten
•
include the name, signature and profession/role of
•
the author
•
include the time of contact, particularly where there are a high volume of interactions in a day.
2
Ethics and Practice Guideline – Case Notes
Updated July 2016
Can I change or amend a case note at a later date?
Care should be taken to avoid errors or omissions. In some instances it is illegal to change, white-out or
amend case notes after the fact.
If a change must be made to correct an error or omission, the change can be recorded as a new and
separate case note. In addition to outlining the error or omission as part of this new case note, it is
advisable to provide an explanation for it earlier absence or inaccuracy. You may also add, if possible, a
note in the margin of the original case note referring the reader to the additional or amended detail.
A case note should never be amended or changed in light of additional information obtained at a later
date. This should always constitute a new case note.
What are my legislative responsibilities with regard to case note recording?
Case notes may be subject to a range of legislative processes and requirements during and following the
conclusion of the professional relationship.
The nature of these requirements may differ greatly according to the State and nature or context of
practice. Statutory bodies, for example, are subject to Freedom of Information legislation, which may
differ slightly from State to State.
In any context, notes can be subpoenaed for any number of reasons. Processes for responding to a
subpoena may differ depending on the Court and similarly organisations may vary in their policy and
procedure for doing so.
Finally, organisations may have policies and procedures for ensuring these and other legislative
obligations are met, in addition to general guidelines for case note recording and management.
For these reasons it is important for Social Workers to:
•
be familiar with the specific legal requirements and processes impacting on practice
•
consider the implications of Federal and State legislation to the recording of case notes
•
understand how these requirements are implemented within their organisation (where relevant)
•
understand what policies and procedures may need to be implemented when working in private
practice.
How should I plan for the termination of a service or support with regard to case
notes?
As noted earlier, Social Workers should include details relating to the termination or interruption of
services or supports in case note entries leading up to or following the end of the professional
relationship.
However, it is also possible that the termination of service is unanticipated. This might include instances
where the Social Worker is incapacitated or unable to continue employment or practice. These are
particularly salient issues for Social Workers who are not part of team, work in private practice or are
geographically isolated.
3
Ethics and Practice Guideline – Case Notes
Updated July 2016
It is particularly important therefore to ensure that case notes are maintained and updated as soon after
an interaction or event as practicable.
This possibility raises a number of issues in relation to security, confidentiality, storage and sharing of
client information in the event of an unanticipated termination of service. These issues are addressed in
detail in the Ethical Guidelines on:
•
Information management
•
Working in Private Practice
•
Remote Service Delivery.
Further information on case notes and their management can be found in the
following Ethical Guidelines:
•
Information management
•
Working in Private Practice
•
Responding to a Subpoena
•
Remote Service Delivery
Ethical Guidelines can be downloaded from the AASW website at http://www.aasw.asn.au/practitionerresources/ethics-and-practice-guidelines or you can contact the Ethics Consultation Service on 03 9320
1044 or at ethicsconsult@aasw.asn.au.
4
Ethics and Practice Guideline – Case Notes
Updated July 2016
Writing Case Notes
MSWPG 7102
CRICOS Provider No. 00103D | RTO Code 4909
CRICOS Provider No. 00103D
What are case notes?
• A ‘case note’ is the term applied to a chronological record of interactions,
observations and actions relating to a particular client
• A formal electronic or paper based record that documents the interaction or
contact between the client & the worker /organisation.
• A written record of a client’s situation, the support they have accessed, an
indication or plan for future work & goals the client wants to achieve.
• Private confidential records that must be stored as such.
• Explain who did what, why, when, where & how.
According to the AASW?
A ‘case note’ is the term applied to a chronological record of interactions,
observations and actions relating to a particular client. (AASW, 2016).
CRICOS Provider No. 00103D
RTO Code 4909
Why do we keep Case Notes?
•
Accountability
•
Legal responsibility
•
To keep a history of the client
•
Work more effectively with clients
•
Enhance planning and review
•
To make referrals
•
Supervision tool
•
Planning
•
Direction
Purpose of Case Notes
•
A written record of a client’s situation, support they have accessed, an indication
or plan for future work & goals they want to achieve.
•
Maps client progress.
•
Communication with other professionals.
•
Accountability for workers, organisations, other services & clients.
•
Enable a team approach & continuity of care.
•
A risk management & quality assurance tool which is part of service funding
agreements.
•
A legal requirement.
•
Protection & prevention for clients, workers & the organisation in legal
proceedings.
•
Reflection & learning tool that can support the review of case plans & strategies
to improve client outcomes.
The Audience
•
Clients
•
Courts of Law
•
Your organisation
•
Managers
•
Team members & other colleagues
•
Police
•
Government Departments
•
AASW Code of Ethics (2020)
•
AASW Practice Standards
What does the AASW say?
Information recorded about a client should be impartial, accurate and complete
with care taken to ensure that:
• only details relevant to the provision of a support or service to which the client
has consented are recorded
• when working with involuntary clients this means recording information
relevant to statutory practice
• notes are free from derogatory or emotive language
• subjective opinions are qualified with relevant background information, theory
or research
• relevant information is not omitted
SOURCE: https://www.aasw.asn.au/document/item/2356
Different types of Case-note writing
Formats for writing case notes: Several different formats exist for writing
case notes. For example:
• S.T.I.P.S. (Signs and Symptoms, Topics of Discussion, Interventions,
Progress and Plan, Special Issues)
• S.O.A.P. (Subjective, Objective, Assessment, Plan)
• D.A.P. (Data, Assessment, Plan)
• F.A.R.M. (Focus, Assessment, Response, Method)
• G.I.R.P. (Goal, Interventions, Response, Plan)
• B.I.R.P. (Behaviour, Interventions, Response, Plan)
Remember that the choice of method depends on your organization’s
policies, personal preferences, and the specific needs of your clients
What goes into Case Notes?
Case notes can be recorded manually or electronically and should:
• include on each page the name and DOB or other identifying information of
the client.
• be dated
• be recorded as soon as possible after an interaction or event
• be typed or clearly readable if handwritten
• include the name, signature and profession/role of the author
• include the time of contact, particularly where there are a high volume of
interactions in a day
(SOURCE: https://www.aasw.asn.au/document/item/2356
•
Only what is relevant to the service being provided
•
Other workers full names, organisation and role
•
Goals, observation, assessment, evaluation of goal attainment, interventions
used, plan for next session, referrals
What stays out of Case Notes
•
Emotional reactions
•
Opinions
•
Value judgements
•
Labelling
•
Unfounded speculation
•
Diagnosing language
•
Information that is not relevant to the support plan or intervention
Source: Take Note! A practical guide to writing case notes (2012) Turning Point Alcohol and Drug Centre
References
SOURCE: https://images.template.net/wp-content/uploads/2016/03/08042500/Case-Notes-for-AOD-Services-PDFTemplate-Free-Download.pdf
CRICOS Provider No. 00103D
RTO Code 4909
What’s wrong with this case note?
22/10
Helen turned up half an hour late.
She smelt like a brewery. I suspect that she had been at the pub before her
appointment which is why she was late/
Still drinking loads.
Isn’t doing the homework from sessions.
GP diagnoses with scitzofrenia.
Goal from last session still the same – talked about things to support that.
Ang
https://insight.qld.edu.au/shop/a-case-in-point-a-queensland-guide-to-alcoholand-other-drug-clinical-documentation-and-case-formulation-insight-2019
What’s wrong with this case note?
CRICOS Provider No. 00103D
RTO Code 4909
Armitage, E (2019, July) A case in point – A Queensland guide to alcohol and other drug clinical documentation and case formulation – Insight,
A good example of the SOAP method
CRICOS Provider No. 00103D
RTO Code 4909
Storage of records and Case Notes
1.
2.
3.
How are records stored? Are they safe and secure?
•
Leaving records on a desk
•
Behind in a photocopier
•
Taking records out of the office
•
Computer/internet security- USB’s
How long are records stored?
•
Legislation for this – check in your state
Who can access or not access the records?
•
Funding bodies/government departments
When storing case records, regardless of the method used, it’s important to consider
data security, backup procedures, and compliance with relevant laws and
regulations, such as those related to data protection and confidentiality.
Organizations will have clear policies and procedures for record storage and access.
19
Confidentiality considerations
• When is information able to be shared with others?
•
When a person gives consent for this
• ‘Consent to Release’ info form
• How much information?
•
When there is a significant risk of harm
• To themselves, to someone else, or to them
• ‘Insiders’ versus ‘outsiders’ in human services
• How much ‘choice’ do people really have?
Relevant Legislation
• Privacy Act 1988
• Privacy Amendment (Private Sector) Act 2000
• The Privacy And Data Protection Act 2014
• Freedom of Information Act
• Information Privacy Act 2000
• Health Records Act 2001
• Public Records Act 1973
• Most of the time this legislation will have
already been incorporated in to your agency
policies & procedures
References
Aasw.asn.au. (2016. Home) Case Notes, AASW – Australian Association of Social Workers
https://www.aasw.asn.au/document/item/2356
Armitage, E (2019, July) A case in point – A Queensland guide to alcohol and other drug clinical
documentation and case formulation – Insight, https://insight.qld.edu.au/shop/a-case-inpoint-a-queensland-guide-to-alcohol-and-other-drug-clinical-documentation-and-caseformulation-insight-2019
Cameron, J (2012, July). Case notes for AOD Sector [PowerPoint slides].
https://images.template.net/wp-content/uploads/2016/03/08042500/Case-Notes-forAOD-Services-PDF-Template-Free-Download.pdf
Cameron, J & Murray, J, Turning Point Alcohol & Drug Centre, (2012), Take Note! A practical
guide to writing case notes: A quick reference guide for alcohol and other drug workers
Case Notes
Case Notes
Case notes are an integral and important part of practice for many Social Workers. Research has shown
that record- keeping practices have an impact on client outcomes such that poor case notes can result in
poor decision-making and adverse client outcomes (see Preston-Shoot 2003, Cumming et al. 2007).
A ‘case note’ is the term applied to a chronological record of interactions, observations and actions relating
to a particular client.
What information should be included in a case note?
The guiding principle for deciding what information should be included in a case note is whether it is
relevant to the service or support being provided.
The type of information that is considered relevant will clearly depend on the context of practice, however
the AASW Practice Standards 2013 provide some broad guidance. This may include:
•
a range of biopsychosocial, environmental and systemic factors impacting on the client. This
includes consideration of an individual’s culture, religion and spirituality
•
risk and resilience factors
•
facts, theory or research underpinning an assessment
•
a record of all discussions and interactions with the client and persons/services involved in the
provision of support including referral information, telephone and email correspondence
•
a record of non-attendance, either by the Social Worker or client, at scheduled and agreed
meetings or activities
•
evidence that the Social Worker and client have discussed their respective legal and ethical
responsibilities. This may include:
o
client rights, responsibilities and complaints processes
o
the parameters of the service and support being offered and agreed to
o
issues relating to informed consent, information sharing, confidentiality and privacy
o
efforts to promote and support client self-determination and autonomy
o
specific responsibilities to clients in particular settings such as private practice or rural
settings as per the Code of Ethics 2010
•
o
professional boundaries and how dual relationships may be managed
o
record keeping and freedom of information
o
discharge planning
o
relevant legislative requirements and their possible implications for practice
details of reasons and any related actions or outcomes leading up to or following the
termination or interruption of a service or support.
1
Ethics and Practice Guideline – Case Notes
Updated July 2016
How should this information be represented in a case note?
There are a number of case-writing models available to Social Workers. Some of them provide general
guidance for writing case notes, such as the ‘Summary Style’, while others are specific to a service type or
context, such as the STIPS model.
In addition, many organisations have policies and procedures around case recording.
The AASW does not recommend the use of one model or policy over any other, however the Code of
Ethics 2010 points to some general principles for good record keeping.
Information recorded about a client should be impartial, accurate and complete with care taken to ensure
that:
•
only details relevant to the provision of a support or service to which the client has consented are
•
when working with involuntary clients this means recording information relevant to statutory
recorded (see sections 5.2.5 (a) and 5.2.4 (b))
practice (see also 5.2.2)
•
notes are free from derogatory or emotive language (5.2.4 (a))
•
subjective opinions are qualified with relevant
•
background information, theory or research (5.2.5 (a))
•
relevant information is not omitted (5.2.5 (c)).
When recording information about third-parties, such as information about a client’s relationship with
significant others, it is equally important to separate fact from opinion.
For more information and for Social Workers in particular settings, such as Private Practice, please see
our related Ethical Guidelines on the AASW website at www.aasw.asn.au/whatwedo/ethics-faqs
How and when should case notes be recorded?
Case notes can be recorded manually or electronically and should:
•
include on each page the name and DOB or other identifying information of the client. This can
be handwritten, typed or constitute an electronic tag where an electronic case recording program
is utilised
•
be dated
•
be recorded as soon as possible after an interaction or event
•
be typed or clearly readable if handwritten
•
include the name, signature and profession/role of
•
the author
•
include the time of contact, particularly where there are a high volume of interactions in a day.
2
Ethics and Practice Guideline – Case Notes
Updated July 2016
Can I change or amend a case note at a later date?
Care should be taken to avoid errors or omissions. In some instances it is illegal to change, white-out or
amend case notes after the fact.
If a change must be made to correct an error or omission, the change can be recorded as a new and
separate case note. In addition to outlining the error or omission as part of this new case note, it is
advisable to provide an explanation for it earlier absence or inaccuracy. You may also add, if possible, a
note in the margin of the original case note referring the
