WHAT IS A CASE NOTE?Case notes are a factual history and chronological recording of data relevant to an injury/illness. They can include details of:
Case notes are used to report and document relevant events, communications and observations relating to a particular person, event or issue.
- 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
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:
WHEN DO I NEED TO WRITE CASE NOTES?
You write a case note after any contact related to a Workers Compensation case.
The following information needs to be included in a case note:
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.
Case notes should contain the following information:
- 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.
It is important that case notes:
|Information Received||Provide a brief summary of the information received or provided, and any impact on the process |
|Action taken||Summarise any action/decision taken.|
|Reasons for Action/Decision||Document what your action/decision is and why you made this decision. |
|Expected Outcome||Specify the expected outcome of your action/decision.|
|Decision Communicated||Describe what method was used to communicate the action/decision, eg email, in person.|
Case notes should not:
- 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.
- 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, clichés, 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: Signed Peter Parsons.
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.