Case Notes for Support Workers

Case notes are a written record of each shift or support session. They tell the next worker what they need to know, track progress towards the participant's goals, show changes in health or wellbeing, and provide evidence of the supports delivered and billed. In this lesson you will learn the many people who rely on case notes, from colleagues and team leaders to health professionals, auditors and the participant themselves. Key points: if it is not written down, it is hard to prove it happened, and the participant has a right to see what is written about them.

Case notes contain personal and often sensitive information, so they must be handled carefully. In this lesson you will learn how privacy law and the NDIS Code of Conduct apply to records, including only recording what is relevant, only sharing information with people who need it, storing notes securely in our approved system, and never using personal phones, social media or unapproved apps for participant information. Key points: participants have a right to access their records, records must be kept for set periods, and any privacy breach must be reported to your team leader straight away.

Knowing what belongs in a case note saves time and makes notes more useful. In this lesson you will learn the core content of a good shift note: the date, times and who was present, the supports provided, progress towards goals, the participant's wellbeing, health and mood, anything unusual or any change, incidents and follow up actions, and communication with others. You will also learn what to leave out, such as personal opinions, gossip, information about other participants and details not relevant to supports. Key point: focus on what the next person needs to know.

Objective notes describe what you actually saw, heard and did, rather than your interpretation or judgement. Subjective words like aggressive, difficult, lazy, attention seeking or in a bad mood are labels that can be unfair, inaccurate and harmful. In this lesson you will learn to replace labels with specific descriptions, to record the person's own words in quotation marks, and to clearly separate facts from any professional observation. Key points: describe behaviour, not character, be specific about what, when and how much, and if you do include an interpretation, say so and give the facts behind it.

Notes should be written as soon as possible, ideally before the end of your shift, while details are fresh. They should be clear enough for anyone to understand, and concise enough to be read quickly. In this lesson you will learn practical tips: write in plain English, use full sentences, avoid slang and unapproved abbreviations, use the past tense, write in the order things happened, and sign or log in so your notes are attributed to you. Key points: never write notes in advance, never write notes for someone else, and always record the time of important events.

The words we use shape how people are seen and treated. Person centred notes put the person first, focus on their strengths, choices and goals as well as their needs, and use respectful, dignified language. In this lesson you will learn to write about the person rather than their diagnosis, to avoid words that are childish, controlling or clinical when they do not need to be, and to include the person's voice, choices and achievements. Key points: record what the person chose and how they took part, not just what was done to them, and use the language they prefer.

Seeing examples side by side is one of the best ways to improve your notes. In this lesson we work through three short scenarios, a community outing, a morning routine and a change in health, and compare a poor note with an improved one. You will see how vague phrases, labels and missing details are replaced with specific, factual, person centred descriptions that tell the next worker what they need to know. Key points: vague notes like had a good day are not enough, include times and amounts, record the person's voice, and note any follow up.

Some events need more than a routine note. When an incident happens, you must record it in the case notes and complete a separate incident report, following our incident management policy. Your case note should give a brief, factual summary and refer to the incident report, without speculation or blame. In this lesson you will also learn how to record changes in health or behaviour, refusals of support or medication, and conversations with family or professionals. Key points: stick to facts, record who you told and when, and never leave out an incident to avoid paperwork.

Case notes are legal records, so they must never be altered in a way that hides the original. In this lesson you will learn how to correct a mistake properly using our system's amendment function, or by a single line through the error on paper with your initials and the date, and why you must never delete, white out or rewrite old notes. You will also learn how team leaders review notes, how notes are used in plan reviews and audits, and how to ask for feedback on your own writing. Key point: honest, accurate records protect participants and you.

This case study follows Ruby, a support worker, and Kwame, a participant with an acquired brain injury whose goal is to catch the bus to his TAFE course on his own. Ruby's first draft note simply says good day, no issues. The lesson shows how she rewrites it to describe what Kwame did himself, the times, his own words and the follow up needed. Key points: link notes to the participant's goals, record the person's independence and choices, and remember that notes like these help at plan reviews and show real progress over time.

This case study follows Hoang, a night support worker in supported accommodation, who finds Beatrice on her bedroom floor in the early hours. The lesson walks through what happens first, making her safe and getting help as her plan and our policy say, and then how Hoang records the fall. You will compare three versions of the case note and see why a brief, factual note that refers to the incident report is best. Key points: safety first, facts not blame, record who you told and when, and never leave out an incident.