Writing Workers Compensation Case Notes

Writing Workers Compensation Case Notes

SUMMARY

The Writing Workers Compensation Case Notes Guideline documents how to write case notes for Workers Compensation files.

GUIDELINE

PurposeTo document how to write case notes for Workers Compensation files.

Guideline

WHAT IS A CASE NOTE?
Case notes are used to report and document relevant events, communications and observations relating to a particular person, event or issue.

Case notes are a factual history and chronological recording of data relevant to an injury/illness. They can include details of: 
  • information provided verbally to and from key stakeholders in the return to work process
  • the progression of a rehabilitation process
  • participation and performance against return to work programs
  • communication.

Case notes supplement other records such as emails, suitable duties programs, medical certificates and may be called as evidence in any legal proceeding.

Case notes need to be:
  • objective
  • concise
  • accurate
  • relevant
  • precise
  • factual.

WHEN DO I NEED TO WRITE CASE NOTES?
You write a case note after any contact related to a Workers Compensation case.

CONTENTS
Case notes must be legible and provide sufficient detail to allow the reader to understand the point of the note, the reasons for any decision made, and how this fits in with the overall management of the case.

The following information needs to be included in a case note:
  • the date of the contact
  • the name and role of the person making the case note
  • the manner and purpose of the contact
  • a factual description of the event
  • details of information provided verbally
  • the purpose of, and reasons for, any decision or action taken in a Worker’s Compensation case
  • details of the decision made, proposed action or action already taken
  • a reference to a policy or procedure authorising the decision or action.
Case notes should contain the following information:
CriteriaDetail
Information ReceivedProvide a brief summary of the information received or provided, and any impact on the process
Action takenSummarise any action/decision taken.
Reasons for Action/DecisionDocument what your action/decision is and why you made this decision.
Expected OutcomeSpecify the expected outcome of your action/decision.
Decision CommunicatedDescribe what method was used to communicate the action/decision, eg email, in person.
It is important that case notes:
  • only record facts eg behaviour observed and statements heard
  • record facts accurately and completely
  • label any ‘opinion’ as an opinion and not factual evidence
  • avoid metaphors or similes - just say what you mean directly
  • use clear, unambiguous, simple, concise language, including professional terminology if appropriate
  • highlight who is doing what in the process
  • are written in the third person.
Case notes should not:
  • include judgmental opinions, stereotypical comments, or any offensive statements
  • make comments that couldn’t be defended in a court of law
  • use slang or street language, clich├ęs, or jargon
  • include sarcastic comments
  • include comment on details irrelevant to the worker’s participation in rehabilitation and return to work activities
  • use abbreviations unless these are in common use (for example, “eg”) or are previously defined.

CASE NOTE EXAMPLE
14/02/2009 - Received a telephone call from Brian Smith. Brian advises that “he is not managing his suitable duties as he continues to experience an increase in pain in his shoulder”. Brian advises that “he is performing all duties required, however, notes that the amount of typing he needs to undertake seems to be increasing his pain”.

Discussed pacing and alternating duties with Brian, who admitted that he is not performing these activities to the full.  Discussed why - Brian “advises he feels uncomfortable stopping work and how this might be seen; he also indicated that he has difficulty in remembering when to stop”.

Action:
It was agreed to meet with Brian and Peter Thimble (supervisor) to discuss Brian’s progress and concerns. I also discussed installing a work pace system or similar system onto the computer to assist with time scheduling.

Brian is to speak with his supervisor and confirm a date to meet by 16/02/2009.

Signed Peter Parsons.

Guideline Information

Contact OfficerManager, Health and Safety
Date Approved23 November 2011
Approval AuthorityManager, Health and Safety
Date of Commencement23 November 2011
Amendment History

n/a

Date for Next ReviewNovember 2014
Related DocumentsReturn to Work Policy / Procedure
KeywordsCase Notes, Workers Compensation
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