Updated and Effective from: October 2024

Purpose

• To clarify what is, and how Lend A Friend uses the Member Notebook & Case Notes
• To explain to Helpers what is, and how to use the Member Notebook & Case notes to benefit Members

Policy

• The “Notebook” is a digital notebook where all the case notes taken for Members are stored
• Each Member has a Notebook which can be found in the Lend A Friend rostering app
• The Care Manager, Helpers who assist the Member, and Members have access to the information in the Notebook
• The information and case notes that should be documented in every Member’s Notebook include information about:
  • Medical appointments that Helpers attended, and what happened in these appointments
  • Incidents that have occurred, or things that merit completing an incident report
  • Any time Helpers are involved with administering of Medication, this should be documented as per the Medication Handling procedures
  • Occasionally, a clearly identifiable task that Helpers have helped Members with, which directly relates to working towards or achieving an NDIS goal, should be documented in the Notebook
• Some things that Lend A Friend might capture in the notebook include:
  • Tracking progress of a Member and how they are working toward their goals
  • Capturing meltdowns and learning:
    • What triggered them
    • How they were managed
    • What works and doesn’t work
  • Documenting outstanding tasks and completed outcomes
  • Taking notes on appointments and medical advice from health professionals and doctors
• When there are outstanding tasks that a different Helper might need to work on with a Member, these tasks and “to do” list should be posted in the Notebook for others to refer to
• Some benefits of thorough case notes include:
  • Easy forwarding of case notes and progress to allied health professionals and other supports so that everyone is on the same page
  • Having clear records of progress, so accurate progress reports and support letters can be made, which assists with NDIS reviews and requests for more funding
  • Transparency and clarity on how Helpers support the Participant
• We realise that each Member is different, has unique needs, and may not need thorough case notes as part of their care.
  • Some Members may request detailed/advanced case notes and record keeping to be completed after each shift
  • Some Members may not require or request case notes to be taken. For these Members, only some information needs to be entered into the the Notebook
  • The Rates Agreement Document provides a space to capture whether or not advanced case notes are required
• Advanced/thorough case notes take more time to write:
  • Generally Helpers will write case notes during a shift or at then end of a shift
  • If there is no opportunity to take case notes during a shift, Helpers will write them as soon as possible after a shift
  • Where case notes are written outside of shift times, the time spent writing these notes is added to the end of a shift
  • Case notes in this scenario are billed as though that shift extended to cover the time spent taking case notes
• Where ****case notes are not requested, at the end of a shift Helpers will clock off and no additional case notes will be captured:
  • This might make it difficult for an accurate progress report or support letter to be written up come plan review
  • Helpers will still document case notes if an incident report needs to be filed or if the case notes are part of the necessary case notes that were outlines above

Related Information and Documents

How to Write Good Case Notes