Course Overview

Good case notes and records assist in providing continuity of care to clients, aid in promoting good practice and service delivery and, provide accountability and protect individual employees and the agency where there may be concerns about the nature or adequacy of the service provided.

For many workers, keeping good case notes and records is difficult because they may not know what to record or how to record. This workshop is designed with detailed guidelines on how to create a simple framework for what to record.

The workshop covers:

• The reasons why case notes and records should be kept; (this section includes a discussion of professional and legal obligations)
• Different types of records
• Common mistakes when keeping case notes and records and how to avoid them
• How to write case notes and keep records in a way that is respectful and allows the worker to discharge their professional obligations
• Writing in a way that is easy to defend and hard to attack and a suggested structure for keeping case notes and records
• Issues regarding confidentiality when keeping case notes and records will also be discussed

Learning Outcomes

At the end of this course, you will have a:

• A greater understanding of professional obligations relating to the keeping of case notes and records
• Increased confidence and skill in writing notes and other records
• An understanding of confidentiality in relation to case notes and records