Case Notes PDF

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Summary

Explanation and examples of Case Notes...

Description

Week 4: Case Notes As part of our role as CYCs we are often required to document our interactions when working with youth. Different agencies and programs will require different documentation. This can range from how a CYC documents interactions, when a CYC documents and what is documented. You will learn more about this in other courses, however we will explore the basics here. An example of documentation is a case note. Do you know anything about writing case notes? Case notes are a concise, specific and clear record of behaviours, incidents, overview of the day, interactions related to a youth you have engaged with at placement/work. Again, the agency/ program would determine what needs to be included in a case note.

Why do we write case notes? Case notes allow us to be accountable in our work as a CYC because we have documentation of our interactions and roles with youth. They allow us to be accountable to: • the agency/program • • •

our Supervisor, fellow staff and members of the multidisciplinary team to agency policy

to the youth with whom we work • Community Collaterals/Service Providers/Ministry It ensures we fulfill our responsibility in our CYC role to document the behaviours, etc. of youth. Case notes need to be treatment focused. This allows us and others working with the youth to determine patterns and possible reason for behaviours, treatment strategies and goals. Case notes provide another form of communication with other faculty, other team members. Case notes can be requested as part of legal investigations. What does concise, specific and clear writing mean? Here's what Dictionary.com's (2020) definition is: "...expressing or covering much in few words; brief in form but comprehensive in scope; succinct; terse."

DO: What you should do when writing case notes: • Describe specific behaviours • Record statements-what did people say? • •

Record your observations not your opinion or judgements Make sure they are clear, accurate and complete

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Complete them on time-completed based on when the agency/program expects them to be completed Make them readable – use acceptable grammar and punctuation. do not include slang,

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text language (i.e. 'u', 'i' ) Use child-centred language i.e. 'The child has a diagnosis of ADD' Use concise, clinical writing

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Person’s feelings/thoughts IF they have stated them-can't be assumed i.e. ‘Client states that he feels angry when…’ NOT ‘Client feels angry when…’

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Indicate where information is from i.e. ‘File states that client was removed from home when they were 3’.

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typically, Case notes are written in the third person: 'This writer observed Youth A kicking the chair.'

DON'T: What you should avoid when writing case notes: • Avoid “diagnoses” i.e. 'He acted like he had ADHD': what does this behaviour look like? Instead of labelling/diagnosing, describe the behaviour that you see. We are not doctors and can't diagnose! •

Avoid judgement, stereotypes, prejudices and judgmental language i.e. 'He acted mean': what does this look like/sound like? Mean to you and to me can mean different things.

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Avoid “street talk”, jargon and slang- use clear, professional language Avoid labelling the child or behaviour i.e. 'an angry kid', 'the autistic child', 'the child who's a pain.' Avoid unprofessional language i.e. 'stuff', 'junk' Avoid unclear language: i.e.'threw a fit', 'gave me attitude': this doesn't tell the reader

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what the behaviour looked like/sounded like. Throwing a fit to you and I can mean different behaviours! Avoid essay/conversational language i.e. not: 'Now I will tell you about...', ‘Next we have...' Avoid your opinion i.e. not ‘I think…’, 'I feel...'

Strong words/verbs to use... These help to ensure your writing is clear, specific and objective: • Stated • Counselled • Discussed • Directed • Encouraged • Focused • Identified • Referred

Words/verbs to avoid... These indicate judgement, opinion, assumptions and do not provide a clear picture of what the behaviour looks like/sounds like: • Abnormal • Abusive • Anxious • Dangerous • Delusional • Demanding • Disturbed • Hysterical • Immature • tantrum • freak out • Impulsive • Irrational • Overwhelmed • Resistant • Suicidal • Threatened • Troubled • Uncooperative • Unfit

Look at the following examples. = #1 "Youth A gave me a lot of attitude today. I think she was really angry. She raised her voice in an aggressive way and threw a temper tantrum. She seems like she's depressed.” #2 "After lunch, Youth A stated to this writer: "I wish you didn't work here. You're a bitch." Youth A kicked over a chair, punched the wall and left the room." What's the difference? #1: -what does attitude look like/sound like? angry?aggressive? what is a temper tantrum -needs to use third person: 'this writer' not 'I' -is subjective: needs to include observation facts i.e. 'I think' is an opinion -CYC doesn't diagnose i.e. depressed; also, this doesn't describe behaviours -needs to be clear, concise, professional #2 -includes what was stated, observed -uses third person: 'this writer' -is objective: describes behaviours instead of interpreting them -doesn't include opinion, judgement Case notes and professional documentation are an important part of our work as CYC's to ensure youth receive optimal support to meet needs. They ensure we are accountable, professional and responsible in our CYC role. They can be used in the court of law if necessary....