It’s the end of a busy day, instead of putting your feet up and having a coffee, you need to write up your notes. There are several good reasons for keeping case notes.
1. Proof of delivery of service:
By keeping track of progress notes, you can demonstrate to clients, their family members, and auditors that the services that were promised, have been delivered.
2. Progress notes can be used legally and as evidence:
Your notes might be used in legal actions, audits, and inquiries. They also establish a documented history that can be referenced in situations of disagreements.
Any occurrences, whether they are proven or merely claimed, need to be reported to the NDIS Commission. This reporting can be done directly or through a supervisor, manager, or designated individual. Additionally, you will likely be requested to furnish proof of progress notes and/or a recording system when undergoing NDIS Audits.
3. Record of customers' achievements and a communication tool:
They reflect a client's movement towards their goals, as identified in their Individual Support Plans, and represent a record of events on each visit or action.
4. Your remuneration:
Whether you are a sole trader/sub-contractor or work for an organisation without your progress notes you do have the proof of the time you have worked on a customer’s behalf.
How to Write Progress Notes
A progress note is not a complete record of a visit or work completed. It's more like a snapshot that captures the essential information about what happened during a visit, and they reflect the work performed on behalf of the customer.
Things to include:
· Reason for the visit/call/email.
· What actions were taken.
· Any follow-ups required.
· Who you called/emailed on behalf of your customer.
· Any important information that is given to you.
· Record of interactions with other providers.
· Visits by providers when important actions are taken like a functional assessment.
TIP
If you need to keep a record of your emails exchanged with customers or providers, organise them in a separate sub-folder within your customer master file. While it's important to ensure that everyone can easily access important information, copying and pasting emails into your Client Management System (CSM) can consume valuable storage space and create difficulties for other team members when searching for relevant details.
When writing your notes, think about how you would view yourself in the same situation: Aim for conciseness but tell a story of what you have been doing.
Your notes should be:
- Specific
- Objective
- Clearly connected to your customer
- Thorough, yet succinct
- You can use recognised formats such as STAR (Situation – Task – Action – Result)
- Keeping specific timestamps and accuracy
Your notes should not:
- Be unclear or ambiguous.
- Lack of specific details which affect an outcome.
- Contain personal opinions or subjectivity.
Effective | Inadequate |
Monday 08052023 Call from XYZ Therapy - discussed upcoming Functional Assessment. Relayed they should call Mary to organise a date. | Nothing recorded |
Called Mary, checking in on her organising a date for the FCA. Mary asked if SC could support her during the assessment. Mary stated she was anxious about the assessment. Checked on Mary's budget and confirmed with Mary that SC could attend. Date 18/05/2023 Time: 10 am Venue: Mary's home Duration: Approx 2 hours plus travel. The event is diarised on the phone with reminders. | Called Mary about the upcoming FCA, checking in to see if XYZ Therapy had been in touch. Mary was agitated on the phone, kept yelling and wanted SC to support her at the meeting, seemed stressed and belligerent as to the purpose of the FCA. Tried to explain when she let me get a word in why it was important. Date 18/05/2023. Reminder: shuffle around other appointments to cater for the meeting. |
Responded to email from ABC supports about hours remaining in the plan | ABC supports emailed wanting to know about the remaining hours in the plan. Told them they need to contact the plan manager and find out. |
Checked with the plan manager and they stated that there was enough funding at current usage and advised it would be easier if SC had login details for Mary. Email received with paperwork ( Not editable) for Mary to sign at the assessment. Follow up: with paperwork and discussion with Mary. | Agreed to call plan manager and they directed me to get a login, which would make life easier. Sent me the paperwork. |
Responded to an email from Mary re: her funding in the capital budget for repairs to her wheelchair | Mary emailed - 5 in total today! Wants to know about the wording in her plan and can she have the repairs done to her wheelchair. Reminder: Talk to Mary at the assessment on the 18/05 |
Follow up: Mary at the FCA meeting about her current support hours and if she feels it is satisfactory moving forward. | Nothing recorded |
Follow up: required with Assistive Technology NDIS - the wording in the plan is ambiguous - clarification sought. | Nothing recorded |
NDIS Call @ 2.30 pm - duration 45 mins Receipt # 51633257356 Mary can use her funding from the capital budget for the repairs | Nothing recorded |
Contacted Mary via email and relayed the information. Mary stated she will contact the repairer herself tomorrow morning. | Nothing recorded |
Emails saved to "Correspondence" in Mary's file | Nothing recorded |
As shown in the example, there are two sides to consider: the left side presents the STAR format, where information is recorded objectively without any judgment. This accurately captures the work done with Mary in a single day.
On the right side, there's a noticeable absence of detail, conciseness, and objectivity. Imagine a situation where Mary requests her file notes due to a dispute or other reasons. In such a scenario, she would read the content written about her. This could have severe repercussions for your customer, with the potential consequences extending significantly to your business and its reputation.
Another point to consider here is the inaccuracy that may arise in your billing. The time spent on Mary is inadequately recorded. The support coordinator could also be panicking on the day of the Functional Assessment as the time was not recorded. Details matter!
TIP
Utilising the terms "stated" or "disclosed" is a helpful approach, as it provides a clear context to your notes and accurately reflects what was communicated. This also ensures that your colleagues have sufficient information in case the client gets assigned to someone else.
Like any skill, becoming competent at writing progress notes requires some initial learning. However, once you've grasped a suitable format, you can build upon it to achieve a more comprehensive approach to your notetaking. This will develop your confidence and ease in sharing your notes with others, including your clients.
The Lama Care Team
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