HTML Preview Social Work page number 1.
1
Ethics and Practice Guideline – Case Notes Updated July 2016
Case Notes
Case notes are an integral and important part of practice for many Social Workers. Research has shown
that record- keeping practices have an impact on client outcomes such that poor case notes can result in
poor decision-making and adverse client outcomes (see Preston-Shoot 2003, Cumming et al. 2007).
A 'case note' is the term applied to a chronological record of interactions, observations and actions relating
to a particular client.
What information should be included in a case note?
The guiding principle for deciding what information should be included in a case note is whether it is
relevant to the service or support being provided.
The type of information that is considered relevant will clearly depend on the context of practice, however
the AASW Practice Standards 2013 provide some broad guidance. This may include:
• a range of biopsychosocial, environmental and systemic factors impacting on the client. This
includes consideration of an individual's culture, religion and spirituality
• risk and resilience factors
• facts, theory or research underpinning an assessment
• a record of all discussions and interactions with the client and persons/services involved in the
provision of support including referral information, telephone and email correspondence
• a record of non-attendance, either by the Social Worker or client, at scheduled and agreed
meetings or activities
• evidence that the Social Worker and client have discussed their respective legal and ethical
responsibilities. This may include:
o client rights, responsibilities and complaints processes
o the parameters of the service and support being offered and agreed to
o issues relating to informed consent, information sharing, confidentiality and privacy
o efforts to promote and support client self-determination and autonomy
o specific responsibilities to clients in particular settings such as private practice or rural
settings as per the Code of Ethics 2010
o professional boundaries and how dual relationships may be managed
o record keeping and freedom of information
o discharge planning
o relevant legislative requirements and their possible implications for practice
• details of reasons and any related actions or outcomes leading up to or following the
termination or interruption of a service or support.
Case Notes