WHY YOU NEED THIS BOOK

Case notes are the formal basis for record keeping in all clinical and many non-clinical settings.

Good quality case notes reflect well on the practitioner and the organisation. Poor quality case notes may compromise the integrity of the programs and services offered, may embarrass the organisation if released under the Freedom of Information Act, and may even be used to determine the outcome of a lawsuit.

You have to get them right.

This book will further develop your skills in writing case notes so that they meet the professional standards required by your organisation.

THE FOLLOWING ASPECTS OF WRITING CASE NOTES ARE COVERED:

• understanding why you need to keep notes

• understanding the legal implications of case notes

• identifying the range of possible readers

• selecting content that is relevant

• keeping your notes accurate, objective and evidence-based

• distinguishing between facts and opinions

• using a template appropriately (where available)

• structuring your case notes logically

• using a clear, concise writing style

• adopting a professional tone

• applying a simple checklist for proofreading notes.

WHAT'S IN WRITING CASE NOTES?

Writing Case Notes is full of concise and practical techniques you can use to improve your case notes.

• First things first - What are case notes? Why are they needed? Who reads them?

• Australian legislative context - Relevant Australian legislation and an overview of the legal implications of case notes.

• Organisational context - Clinical and non-clinical settings, organisational policies on note taking and storage, record keeping systems and practices, electronic versus written case notes, open fields versus structured headings and a suggested organisational framework.

• Principle One: Case notes should be timely - What does 'contemporaneous' mean? Common barriers to writing notes in a timely manner and tips for writing notes in a timely manner.

• Principle Two: Case notes should be accurate - Distinguishing between four types of information in case notes; being clear about who said what; when to use quotations and direct speech; and useful reporting verbs.

• Principle Three: Case notes should be relevant - Identifying the critical information; summarising key issues; determining how much detail to include; understanding what not to include in case notes; and how to document supplementary information.

• Principle Five: Case notes should be objective - Recording behavioural observations; writing factual statements not value judgments; avoiding emotive and politically incorrect language; using inclusive language; and recording difficult conversations.

• Principle Six: Case notes should be clear - Using short paragraphs to record information of one type; using short sentences; being precise; using active voice; using dot points and bulleted lists; avoiding jargon, clichés, idiomatic terms; and defining acronyms and abbreviations.

• Principle Seven: Case notes should be grammatically correct - Using complete sentences; avoiding commonly confused words; using the correct tense for the situation; matching subject and verb correctly; and tips for proofreading your case notes.

• Case studies, exercises, tools - Auditing checklist & useful tip sheets