You have been in the sector for a while. Would you be able to share with us how you managed
to keep your case notes updated? What is considered “up-to-date”?
Yoges
After every case work or counselling session, I will immediately set aside time to
complete my case work notes. This is a practice that I always had since my
school based counselling days and it became even more structured after my
child protection days in Perth.
I make sure that there is minimal time lapse so that my recording is accurate
and captures key issues and assessment. It is often harder to recollect past
sessions and the process takes longer. My pre-session plans also go into my case
notes.
The same goes for my notes of supervision sessions of my social workers.
Iris
I agree with Yoges. I will try to do my case notes immediately after seeing my
clients. I find that planning my schedule in advance is very helpful so that I can
ensure I have at least 30 min for each case recording.
This is by far the best way, for me, in terms of documentation and casework
management so as to make sure documentation is up to date. In the event if I
am unable to do them on the same day, I will try to do them the following day
and will usually finish it up in the same week. As mentioned, I usually plan my
schedule in advance and allow for pockets of time for case notes.
Jim Jim
I also do try to make sure there are minimal time laps. I would key in the case
notes (into our computerised case management system) before the next
meeting with the client so that I am reminded of the follow-up action required,
if any, and think through what is the overall goal for the next session.
Chey May
In healthcare it is a little different. The patient usually stays for a short period of
time, about 5 – 8 days, and very much like doctors, we will write down the case
notes on the spot.
There are two types of case notes, one is the written notes (progress notes in
the patient’s casefile) and the other one would be the department notes which
is being keyed into the computerised case management system within each
health cluster. Notes in both places are a little different as MSWs work in a
multidisciplinary setting and department notes are viewed by other
professionals. There is a challenge to key in the information into the system on
time as it is more precise and formatted.