As a Support Coordinator, your primary responsibility is to connect individuals with services and supports that align with their NDIS goals. As a best practice, you must also be able to document each individual's case in detail. Case notes serve as a record of the services provided and the individual's progress over time. They also provide critical information that can be used to make informed decisions about service provision and delivery of future services.
Unfortunately, writing effective case notes is not always easy. It can be challenging to strike the right balance between providing too much information and not enough, between writing in 'code' that only other Support Coordinators will understand and using jargon that bewilders everyone else.
For example, today, I spoke with the LAC and submitted a ROC to the SIL team.
For many people, this may seem like jargon. Particularly others who don't work in the NDIS space and potentially the Participant who may be requesting copies of their case notes.
The good news is that you can use some simple strategies to write effective case notes.
By planning and organising your thoughts before you start writing and using clear and concise language, you can produce case notes that are both informative and helpful to anyone reading them.
Planning Your Case Note
Before you start writing your case note, take a few minutes to plan what you want to say. A good way to do this is to list the main points you wish to include. This will help you stay focused as you write and ensure that all the important information is captured.
It can also be helpful to jot down a few keywords or phrases you want to use in your case note. This will remind you of the terminology specific to your field and help you avoid jargon that could confuse or frustrate others.
Finally, take a moment to consider the tone of your case note. Remember that case notes are a record of what has happened, not your opinion of the situation. As such, they should be objective and factual. If you find yourself getting emotional or opinionated as you write, take a step back and refocus on the facts of the case.
Writing Your Case Note
Once you have planned what to say, it's time to start writing your case note. Start by documenting the date, time, and location of your interaction with the individual.
Sidenote: If you are using Support Coordination software to manage your business. It is highly likely that when you create the case note, things such as date, time and whom you are writing the case note will automatically be included or reflected when entering your case note.
But always check to be sure!
Then, provide a brief overview of what happened during the interaction. Include any important details or highlights; for example, if the individual expressed interest in receiving housing assistance or spoke about their first appointment with Occupational Therapist, you should document this!
Next, detail what services were provided during the interaction. Be sure to include information about who provided the services (e..g., yourself, Support Worker, Team Leader), as well as when and where they were delivered. If more than one service was provided during the interaction (e..g., an assessment was conducted in addition to connecting the individual with housing assistance), be sure to document each service separately. This allows you to easily identify and find case notes relating to different services.
Finally, document any required follow-up actions (e..g., scheduling another meeting with the individual) and identify who is responsible for taking those actions. This will ensure that follow-up is conducted in a timely and effective manner.
What a case note might look like
Date of case note: 22/09/2022
Work completed on: 22/09/2022.
Communication type: Face-to-face meeting
Research & preparation: Researched local providers for group activities based on the previous discussion with Jack and his interest in joining a local fitness group.
Total Hours: 1.5 hours
Travel: 30 minutes
Note: John met with Jack to discuss support options for group activities at his residence at Edgeworth. Jack was shown three different options offered by local providers and was explained the differences between each program. Some of the differences included one provider offering travel to and from support, another having a higher out-of-pocket cost, and the third did not offer travel. As John was hoping to be transported to and from the group, he chose the first option - 'All Access Fun'.
Outcome: John chose a new provider for group activities.
Follow-up required: Send a referral to All Access Fun.
Other considerations
Who might read your case note?
Don't forget that many different people may read your case note, including the Participant, the plan nominee, carers, future Support Coordinators, Tribunals and the NDIS Quality and Safeguards Commission.
Privacy and confidentiality
Be mindful that case notes may contain personal information about the person you support and should be treated as confidential. Case notes should only be shared with people who need to know the information for the purpose of providing support.
In some instances, you may wish not to share certain details directly with the Participant or their nominees. For example, in the event that the Participant has requested not to share information with the nominee. In an instance like this, you may wish to write a separate case note or document it using a different system - on paper, for example, or within a word document.
