What advice do you have for social workers to keep their case notes updated? Please share
with us 3 tips.
Iris
Firstly, I would advise them to plan their schedule in advance. That's when
boundaries are set in place.
Secondly, discipline is very crucial. One needs a lot of discipline to do the notes
even though it might not be the most enjoyable part of the work.
Thirdly, they must stay focus on the reason why case notes is important and
necessary.
Yoges
Agree! Scheduling is key in making sure that time is set aside for case notes. They
should make sure they calculate and indicate on their calendar the time needed
for their case recording in addition to the session.
Jim Jim
Documentation and understanding its importance in client outcomes and
professional accountability helps us be more conscientious about case notes.
Like Iris, I would recommend them to schedule in advance by putting it in their
“To Do” list. They should also make time to key in the case notes as part of their
weekly schedule. Most importantly, they need to keep their case notes concise.
Chey May
Yes, concise case notes are a must! However, it should include detailed
information where necessary. They should write down detailed notes so that it
would allow others who read the case notes to understand the case better. This
helps when duties are being covered. They also need to be timely in keying in
their documents so that the information would still be as accurate as possible.
Healthcare professionals also have to follow the JCI (Joint Commissions
International) standards (e.g. authorship, date and time of documentation, no use
of unrecognized abbreviations, etc.)
Yoges
My view is that they should keep their recordings along main points and headers
which apply to all casework practice, local or overseas, and across social service
sectors.
Another tip would be to print out or develop forms with pre-established
headings. What’s essential is thorough assessment and follow up, not just
narratives of what happened in the session. Sometimes, I find it helpful to draw
visuals of recurring patterns to provide clarity in my assessment.