NDIS Scenarios and Case Noting

A case note is the official record of the support you provided. In this lesson you will learn who reads case notes and why they matter so much. Key points: case notes give the next worker the information they need, they are evidence that supports were delivered as agreed, they help us spot risks and changes early, and they can be read by the participant, your team leader, clinicians, auditors and the NDIS Quality and Safeguards Commission. That is why we ask you to write every note as if the participant is reading it over your shoulder.

Good case notes share five qualities. In this lesson you will learn to write notes that are objective, factual, timely, person centred and respectful. Key points: describe what you saw, heard and did rather than your opinions; write the note during or straight after the shift while details are fresh; use the person's name and their own words; avoid labels such as difficult, non compliant or attention seeking; and describe behaviour rather than judging it. A good note lets a reader who was not there understand exactly what happened.

Knowing what belongs in a case note is as important as how you write it. This lesson covers the core content of every note, a simple writing sequence, and what to leave out. Key points: include the date, times, support provided, the participant's choices and wellbeing, anything unusual and any follow up needed; leave out gossip, personal opinions, other participants' names and details that are not relevant. Case notes contain personal and health information, so store and share them only through our approved system and never on personal devices or social media.

Our first scenario is about choice and control. Tomas is 34 and has an intellectual disability. He tells you he wants to catch the bus on his own to watch his local footy team, something he has never done. His sister has texted you asking you not to let him go. In this lesson we set up the situation and look at what is at stake: Tomas's right to make his own decisions, his sister's genuine worry, his safety, and what his support plan and risk assessment currently say.

This lesson shows the right response to Tomas's request and why. Key points: the first element of the NDIS Code of Conduct requires us to respect a person's right to self determination and decision making; supporting choice does not mean ignoring risk, so talk the plan through with Tomas and involve your team leader because a first solo trip is new and may need a risk assessment; respond respectfully to his sister without sharing private information; and never make the decision for Tomas or record his choice as a behaviour problem.

This lesson walks through a model case note for the Tomas scenario. You will see how the note records Tomas's choice in his own words, the steps the worker took, the outcome and the follow up, without judgement. Key points: record the participant's decision clearly, show the reasoning and who was consulted, note contact with family factually without repeating private details, and list follow up actions such as updating the travel risk assessment. We also compare the model note with a weaker version so you can see the difference.

Our second scenario is about safety and incident response. You arrive for a morning shift and find Mei, a participant who lives alone, on her bathroom floor. She is conscious and says she slipped during the night and her hip hurts. In this lesson we look at your first minutes on scene. Key points: check the area is safe, do not try to lift or move her, call 000 for an ambulance, stay with her and reassure her, give first aid only within your training, and contact your team leader as soon as it is safe to do so.

Once Mei is in the care of paramedics, your job is not finished. This lesson covers what to report, to whom and why. Key points: tell your team leader straight away and complete an incident report in our system before the end of your shift, following our incident management policy; your team leader decides whether the incident must be notified to the NDIS Commission; the Code of Conduct asks us to provide supports safely and to promptly raise concerns about quality and safety; and never delay, downplay or guess at the cause in your report.

This lesson shows a model case note for Mei's fall. Key points: record the exact time you arrived and found her, what she said in her own words, what you did and when, who you contacted, and what happens next. Describe injuries and pain only as observed or reported, without diagnosing. Make sure the case note and incident report tell the same story. Avoid guesses such as "she must have been rushing" and avoid blame. A clear, factual note helps paramedics, hospital staff, your team leader and any later review.

This scenario is about professional boundaries. Jack, 27, has worked with you for six months and you get on well. He sends you a friend request on social media, offers you fifty dollars for your birthday and invites you to his party on your day off. In this lesson you will learn how to decline warmly, why boundaries protect both Jack and you, how our gifts and social media policies apply, and why you should tell your team leader. We finish with a model case note.

This scenario is about medication. Rosa has a back injury and her medication plan lists her regular medicines in a pharmacy packed blister pack. One evening she asks you to give her extra tablets from a bottle in the cupboard that is not on her plan, saying her daughter usually does. In this lesson you will learn the rule: workers only assist with medication they are trained and authorised for, following the medication plan. You will learn how to respond, who to contact, and what never to do.

This lesson shows a model case note for Rosa's scenario and the extra care needed when writing about medication. Key points: record what was given, what was not given and why, the participant's words and wellbeing, who you contacted and what they advised. Record medication on the medication chart as well as in the case note, as our medication policy requires. Never record a dose you did not see taken, never write a note in advance, and report any medication error or near miss to your team leader straight away.

Our final scenario is about cultural safety. Daniel is an Aboriginal man who lives in supported accommodation. He tells you a family member has passed away and he needs to go home to be with family and community for an unknown length of time. In this lesson we set up the situation and explore what cultural safety means: it is defined by the person receiving support, not by the worker. Key points: listen, do not pry, respect cultural obligations and ask Daniel how we can support him.

This lesson covers the right response to Daniel's news and why it matters. Key points: offer condolences and listen; ask what Daniel needs rather than deciding for him; tell your team leader so supports, travel and rostering can be arranged flexibly; respect his privacy about family and cultural matters; and respond to the relief worker's comment respectfully but directly. The Code of Conduct asks us to respect each person's rights, including culture and decision making, and our cultural safety policy asks us to challenge disrespect when we see it.

In this final lesson you will see a model case note for Daniel's scenario and review the whole course. Key points: record the support provided and Daniel's wishes, while keeping private family and cultural details out of the note unless he wants them recorded; use respectful language and the terms Daniel uses himself; record who was told and what happens next. We then summarise the course: good case notes are objective, factual, timely, respectful and private, and in every scenario the right response puts the participant at the centre and involves your team leader.