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)