This SOP outlines the process for creating and maintaining accurate, clear, and compliant case notes for Support Workers & National Disability Insurance Scheme (NDIS) participants. The goal is to ensure that case notes are a reliable source of information for future reference, handovers, and compliance.
1. General Guidelines
- Accuracy: Case notes must accurately reflect the events and discussions that took place. Avoid personal opinions or assumptions.
- Legibility: Ensure all notes are clear and easy to read, whether handwritten or digital. Use plain language, minimising jargon to ensure notes are understandable by a wide audience, including other NDIS support coordinators and auditors.
- Timeliness: Write case notes in real-time or as soon as possible after the meeting or event to ensure accuracy.
- Confidentiality: Case notes should comply with privacy laws, including the NDIS Practice Standards and the Australian Privacy Act 1988. Sensitive information must be stored securely and only accessible by authorised staff.
- Professionalism: Maintain a respectful and professional tone at all times. Notes should reflect objective facts, not personal opinions or feelings.
2. Components of a Good Case Note
A thorough case note must include the following components:
a. When It Happened
- Date: Clearly specify the date of the interaction.
- Time and Duration: Note the time the event or conversation started and ended.
- Location: Specify where the meeting took place (e.g., participant’s home, office, telehealth).
b. Who Was Present
- Names: Record the names of all participants involved in the interaction, including staff, family members, and the participant.
- Roles: Identify each person’s role in the meeting (e.g., participant, support coordinator, family member).
c. What Was Discussed
- Key Points: Summarise the main points of discussion using simple, clear language. Include:
- The participant’s goals, concerns, and feedback.
- Any advice or options provided.
- Responses to the advice.
- Any decisions or agreements made.
- Important Details: If any crucial details were mentioned (e.g., changes in health or living conditions), ensure they are recorded.
- Quotes (if relevant): If a participant or stakeholder made a significant statement, quote it directly to capture exact language.
d. Next Actions
- Follow-Up Actions: Clearly outline any actions to be taken, including:
- Tasks assigned to team members or other stakeholders.
- Expected timeframes for completing the actions.
- Pending Issues: Mention if any issues need further investigation or attention.
- Instructions: Include any instructions provided to the participant or family members.
- Handovers: Ensure that the case notes contain enough detail so that if another support coordinator takes over, they have a clear understanding of the next steps.
3. Practical Tips
- Real-Time Note-Taking: Where possible, take notes during the interaction or meeting to capture information accurately. Finalise the case notes as soon as the meeting ends.
- Templates: Use case note templates to streamline the process and ensure all key information is consistently captured.
- Avoid Jargon: Minimise the use of technical or sector-specific terms unless they are essential for accuracy.
- Technology: Utilise available technology such as voice recording (with consent) or note-taking apps to improve efficiency.
4. Compliance and Security
- Data Storage: Ensure that all case notes are stored in a secure, compliant manner as per the NDIS Quality and Safeguards Commission guidelines.
- Confidentiality: Access to case notes should be limited to authorised staff only. Always comply with the participant’s consent regarding the sharing of personal details.
5. Review and Handover
- Peer Review: Periodically, case notes should be reviewed by peers or supervisors to ensure consistency, accuracy, and compliance with NDIS standards.
- Handover Procedure: In the event of a handover to another team member or NDIS worker, ensure the case notes provide a complete and clear account of the participant’s situation, history, and the next steps.
6. Examples of Case Notes
- Example 1:
- Date: 22nd September 2024
- Time: 10:00 AM – 11:00 AM
- Attendees: Ash Patterson (Support Coordinator), Jane Smith (Participant)
- Discussion: Jane expressed concerns about her current SIL provider. Options for alternative services were discussed. Jane agreed to explore new SIL providers in her area.
- Next Actions: Ash to email Jane a list of available SIL providers by 25th September 2024. Jane to review and decide on her preferred provider by 1st October 2024.
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