Writing Professional Case Notes - The essential reference for anyone who writes case notes

Why you need this book

Case notes are the formal basis for record keeping in all clinical and many non-clinical settings.

Good quality case notes reflect well on the practitioner and the organisation. Poor quality case notes may compromise the integrity of the programs and services offered, may embarrass the organisation if released under the Freedom of Information Act and may even be used to determine the outcome of a lawsuit.

You have to get them right.

This book will further develop your skills in writing case notes so that they meet the professional standards required by your organisation.

The following aspects of writing case notes are covered:

Understanding why you need to keep notes
Understanding the legal implications of case notes
Identifying the range of possible readers
Selecting content that is relevant
Keeping your notes accurate, objective and evidence-based
Distinguishing between facts and opinions
Using the template appropriately (where available)
Structuring your case notes logically
Using a clear, concise writing style
Adopting a professional tone
Applying a simple checklist for proofreading notes

What's in Writing Professional Case Notes?

Writing Professional Case Notes is full of concise and practical techniques you can use to improve your case notes.

Introduction Aims, objectives & book outline.
First things first What are case notes? Why are they needed? Who reads them?
Australian legislative context Relevant Australian legislation and an overview of the legal implications of case notes.
Organisational context Clinical and non-clinical settings, organisational policies on note taking and storage, record keeping systems and practices, electronic versus written case notes, open fields versus structured headings and a suggested organisational framework.
Principle One: Case notes should be timely What does 'contemporaneous' mean?, the 3 stages of writing case notes, common barriers to writing notes in a timely manner and tips for writing notes in a timely manner.
Principle Two: Case notes should be accurate Distinguishing between four types of information in case notes; Attribution: being clear about who said what; when to use quotations and direct speech; and useful reporting verbs.
Principle Three: Case notes should be relevant Identifying the critical information; summarising key issues; determining how much detail to include; understanding what not to include in case notes; and how to document supplementary information.

Principle Four: Case notes should be logical Narrative versus Issues approach to writing case notes and a suggested organising framework.
Principle Five: Case notes should be objective Recording behavioural observations; writing factual statements not value judgments; avoiding emotive and politically incorrect language; using inclusive language; and recording difficult conversations.
Principle Six: Case notes should be clear Using paragraphs to record information of one type; using short sentences; being precise; using active voice; using dot points and bulleted lists; avoiding jargon, clichés, idiomatic terms; and defining acronyms and abbreviations.
Principle Seven: Case notes should be grammatically correct Using complete sentences; avoiding commonly confused words; using the correct tense for the situation; matching subject and verb correctly; and tips for proofreading your case notes.
Building team capability Action plans and next steps.
Case studies, exercises, tools Auditing checklist & a useful tip sheets

Who Wrote This Book?

Hi, my name is Sheryl Ward. I run a Melbourne-based business writing consultancy called Training Works

Training Works runs a wide variety of business and government writing workshops.

One of the most popular programs we have run for the last 10 years has been our Case Notes program.

I have now taken everything that I have learnt from that experience and produced this book as a useful reference and development guide for those who write case notes on a regular basis.

If you have any questions, I'd love to hear form you. You can also follow me on twitter.