Astalty

Effective case notes are essential in the NDIS sector, providing valuable insights into the support provided, ensuring continuity of care for Participants, mitigating legal risks, and tracking progress toward Participant goals.

Despite their importance, many businesses struggle with case note documentation, often facing challenges such as unclear expectations, inconsistency in documentation, and difficulties in getting Support Workers to complete their notes after each shift.

To help providers navigate case notes, we’ve developed a practical guide for case note documentation and management.

Setting Your Team Up for Success

Let’s get straight to it—holding your team accountable starts with you. As a business owner, you can’t expect great performance if you haven’t first provided the right tools, guidance, and expectations.

Before addressing any concerns with a team member, I always ask myself:

Have I set clear expectations?
Have I provided the necessary training and support?

It’s not fair to hold someone accountable for something they were never properly guided on. If expectations aren’t clear or training hasn’t been provided, then the issue isn’t with the worker—it’s with leadership.

Before taking the route of performance management, first ensure that you've provided thorough training and set clear expectations for your team.

Training Your Team: How to Reinforce Good Documentation Practices

If your team isn’t meeting the documentation standards, now is the time to reset expectations. Consider the following:

Running a toolbox session – Gather the team to go over the importance of case notes and provide training.
Recording a training session – If staff can’t attend, a recorded version can be shared and used for future training.
Using real-life examples – Demonstrating why accurate documentation matters helps reinforce the importance.

For example, I recall when I was a Support Worker many, many years ag,o my employer at the time told a story about where a client in out-of-home care made a serious accusation against a Support Worker, including detailed personal information about them, which included their home address. The Support Worker had documented in their case notes that they had lost their wallet during support, which was later found by the Participant. Because the Support Worker had documented this event, it provided crucial context around how the Participant knew about the Support Worker's home address.

For me, this highlighted why documenting everything on support is critical, whether it's losing your wallet, conversations that were had on support, and any interactions throughout the support.

Using a Template for Consistency

One of the best ways to assist Support Workers in writing quality case notes is by providing a structured template. This removes the burden of remembering what to include and guides them through the process. A good template might include:

Date & Time of Support
Participant Name
Summary of Support Provided
Medication
Observations
Incidents or Concerns
Next Steps & Follow-Ups

This structured approach ensures that important details aren’t missed and provides a clear reference for future support.

Case Notes – When is the Right Time?

Different organisations have different standards and expectations around case note documentation—some require notes to be completed immediately after a shift, while others allow them to be done during support. However, a common challenge for many Support Workers is simply finding the time to complete them.

One approach that has worked well in our organisation is communicating to Participants that Support Workers need 10 minutes at the end of each shift to complete their notes.

Where appropriate, Participants can even be involved in this process by describing their own day, ensuring their perspective is captured. This approach, inspired by Open Future Learning’s "partnership documentation", is a fantastic example of person-centred practice—I highly recommend checking out their module on it.

That said, this method doesn’t work in every situation, and not all Participants will want to be involved—which is completely fine. Even so, we still set the expectation that Support Workers should have dedicated time at the end of their shift to complete their case notes. Ensuring documentation is done accurately and in a timely manner

What’s the Right Tone for Case Notes?

Case notes should always be professional, objective, concise, and written in the third person. It's important to avoid informal language and personal opinions, ensuring that documentation remains factual and neutral. Support Workers should stick to the facts and avoid making assumptions, as inaccurate or subjective information can lead to misunderstandings.

Keeping case notes clear and to the point helps streamline communication and ensures that important details are easily understood by others. Additionally, writing in the third person maintains a professional tone and keeps documentation consistent, allowing for a more structured and impartial record of the support provided.

Regularly Reviewing Case Notes

Regularly reviewing case notes is essential to maintaining a clear understanding of what is happening during support. Having a structured process in place ensures that the team stays informed and up to date on Participant needs and any changes in their support.

Case notes provide some of the most valuable insights into a Participant’s progress, challenges, and overall well-being. Client Liaison Officers, Team Leaders, and Case Workers should make it a priority to review documentation consistently, allowing them to stay engaged and responsive to supports. This not only helps maintain great support but also provides an opportunity to check in with Participants or Support Workers when necessary, ensuring any concerns or updates are addressed promptly.

Tracking Participant Progress Through Case Notes