Updated and Effective from: November 2024

Purpose

Clearly explain to Helpers how to write good case notes, and how to use the Notebook

Policy

Case note should be written using objective language. This means describing things exactly as they were witnessed, not how you interpret the situation. Below are 2 examples of case notes:
- Subjective case notes (The wrong way): Today Jessica was really sad, I think it’s because her friend was bullying her. I listened to her, told her some jokes, and she felt better afterwards.
- Objective case notes (The correct way): Today on arrival Jessica was crying and said she was sad. When I asked her why she said she didn’t want to talk about it. After listening to her and talking for a while she said she was being bullied by her friend. We continued talking and I made some jokes. She was not crying and was smiling more at the end of the shift, appearing happier than when I arrived.
Case notes must be taken when medication is administered. You must document:
- Time of medication taken
- Dose of medication
- Name of medication
- Any side effects that were witnessed
When there are outstanding tasks or a “to do” list to work on with a Member, the tasks should be posted in the Notebook or other private communication platform so any other Helper who visits the Member will be up to date with what tasks are outstanding. When a task is completed, it can be documented as such in the notebook.