Are you collecting case notes effectively?

From the perspective of an NDIS provider there are three big reasons to ensure you’re getting case notes right.

  1. It’s a requirement of your NDIS registration
  2. It makes it easier for your whole team to coordinate care for each participant
  3. It helps ensure that you’re identifying and addressing ways to help clients achieve goals.

Why keep case notes?

To implement your service agreements with participants, you’ll need to deliver services over time. That means multiple appointments and meeting both short and long-term goals. It will also require building up your knowledge of—and relationship with—each client, over time.

It makes sense that you’d need notes or records of some kind to help you stay focused, assess each client’s ongoing needs and monitor and refine how you are helping participants’ achieve their goals. Research has shown that poor record-keeping can adversely impact client outcomes, due to poor decision-making.*

Quality notes made during or following each session can help ensure you’re on track to deliver intended outcomes, or to identify and address any barriers to achieving outcomes as they arise. Case notes also enable greater continuity of care, especially when multiple support workers are involved in a person’s care.

Registered NDIS providers are expected to monitor and document how their services are contributing to reaching each participants’ goals in their plan. Being paid and remaining compliant with the scheme is also dependent on keeping full and accurate records of supports and services.

The NDIS Terms of Business state:

A Registered Provider must keep full and accurate accounts and financial records of the supports delivered to NDIS participants, along with records of service agreements. The accounts and financial records must be maintained on a regular basis and in such detail that the Agency is able to accurately ascertain the quantity, type and duration of support delivered.

What do you need to include in case notes?

Case notes are factual accounts of what happened during each instance of service delivery. At a minimum, according to the NDIS Provider Toolkit (Section 7), records should include:

  • Participant’s name
  • Date/s and total hours or quantity of the support delivered
  • Support type.

It’s also important to be clear about who created each note.

While providers need to be vigilant about writing and retaining case notes, the notes themselves do not need to include every detail of a session—just a summary of the relevant events and outcomes.

Depending on the service you are providing your case note might include information such as:

  • What activities, interactions or communications occurred?
  • How did the session contribute to the participants’ goals?
  • Did anything happen during the session to trigger concerns?
  • Did the client display changes in behaviour, resilience or mood?
  • Did anything happen that was cause for celebration or joy?
  • Did something happen that will affect what needs to occur in the next session?
  • Did anything occur that increased risk for this client?
  • Did the client raise a question, issue or complaint of a legal or ethical nature?

Consider the fact that if a dispute or issue arises where your service’s actions or quality of care comes under scrutiny, the details included in your case notes may provide important evidence.

How to capture great case notes?

There are no hard and fast rules about how to capture and store case notes. You can store notes electronically or on paper, but remember that the NDIS requires you to have information easily accessible at all times if they ask for evidence of support delivery.

The NDIS Terms of Business state that records must be retained by providers for ‘a period of no less than 5 years from the date of issue.

Many organisations find that for security and peace of mind, an electronic system to record and store case notes is preferable.

The advantages of a cloud-based case management system are many—data is protected, actions and notes can be associated with specific users and clients, information can be easily managed at the organisational level, and is accessible at any time online.

Case management software that has been designed to work seamlessly on mobile devices, like Comm.care by Pnyx, means case notes can be recorded as soon as possible while information is fresh in your mind.

Being able to collect case notes via software with integrated care coordination features helps you manage your business with greater ease.

The collaborative interface within Comm.care means other users involved in a person’s care can easily see and comment on notes to provide further context or ask for clarification—that keeps everyone accountable and informed.

Also, the progress/case notes recorded for a specific client via Comm.care can be automatically collated by the system to enable you to generate a support log or invoice that you can share with clients or plan managers—which is a requirement of the NDIS.

Progress notes within Comm.care also form the basis of bulk NDIS upload reports that can be exported from the system and uploaded straight into the NDIS myplace portal. That allows you to streamline your processes and get paid for agency-managed clients promptly.

Case notes are an important part of managing your business and your obligations under the NDIS, as well as helping clients achieve better outcomes. Great case notes are made more achievable by adopting a fully featured case management system such as Comm.care by Pnyx.

For more information or a free online demo, get in touch today.

*Ethics and Practice Guideline—Case Notes, Australian Association of Social Workers, July 2016—web link.