Write for the next person who opens the record
A useful case note explains the service delivered, the participant’s response and what needs to happen next. Someone who was not there should be able to follow the sequence without guessing. Keep observations separate from what the participant or another person reported.
A practical note structure
- Context: participant, date, contact method, people involved and purpose.
- Work completed: the actions you took and their connection to the participant’s goals.
- Response: what the participant said, chose or did. Attribute other people’s information.
- Next action: the task, responsible person and agreed follow-up date.
- Service record: actual duration and any separate billing detail that needs review.
A fictional example
“Phone call with Alex about the first community-group visit. Alex said the venue was suitable but the afternoon transport arrangement had fallen through. With Alex’s agreement, emailed the provider to ask about an earlier group. Follow up with Alex on Thursday after the provider responds.”
This records the issue, participant preference, action and follow-up. It does not claim a result that has not happened. Record the duration in the appropriate service field rather than padding the narrative.
Review before finalising
Check the participant, dates, names, permissions and attachments. Replace vague phrases such as “all sorted” with the action actually completed. Remove information that is irrelevant to the service. Follow your organisation’s correction process if a finalised record needs changing.
SOAP, BIRP and DAP can help organise a note, but the structure does not make a note accurate. Explore the template library or see the CordoCare case-note workflow before choosing the format your team will use.