Why is it important to maintain a good level of records?

  • For training purposes
  • For continuity of service
  • For handling of complaints
  • To accurately reflect the interaction with the client
  • To record outcomes and monitor statistics 

What information should be recorded in case notes? 

  • What is the client’s key issue(s)
  • What outcome the client wants to achieve 
  • Barriers to achieving this?
  • Information and options (recording the information sources)
  • What information did you give the client in the appointment? 
  • Has the client given you consent to act on their behalf? 
  • Decisions made 
  • What action has been taken 
  • What further action has been agreed, if any (Agreed action plan)



Diagnosis Information



Checklist for appointment