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Social Care Tips: Throughout my career, there has always been confusion or conflicting information on how social care practitioners should write up a case note contact with a Service User.
I cannot underestimate the value or importance of completing case note contacts – particularly given my involvement in an inquest whereby 300 contacts were made available for cross-examination. Whilst this did not stop a serious incident occurring, as a practitioner, I felt ‘protected’ because I had evidenced my involvement and the work I had undertaken.
However, do not confuse the need to complete case note contacts for defensive reasons. Moreover, they should be used to make defensible decision making. What I mean by this is highlighting the work undertaken linking it to assessment, planning and subsequent intervention delivery. This though is on the proviso that it is done correctly, with the emphasis on the quality of the content and not on providing reams of descriptive and irrelevant information. Remember, contacts should be SMART – Specific, Measurable, Achievable, Realistic and Timely.
As such, I have created a 7 step guide to assist social care professionals in completing a case note contact and what should constitute as ‘good’ or sufficient standard. Remember, its not about the tail wagging the dog, it is about making defensible decision making!
You can use each step as a heading to assist.
Evidence and write down who attended plus contact details, if applicable. e.g. young person and parent/carer or multi-agency professionals.
2) Where did the contact take place/time of session
This is important. It should be noted here that any good social care practitioner worth their salt should undertake and complete at least one session within the home setting per month (minimum). Sometimes this must be carried out weekly, depending on nature of service involvement. If the intervention will focus on ‘home circumstances’, then completing this in the home environment will not be conducive to the needs of those involved. Use professionals judgement throughout.
3) Purpose of the session linked to intervention
Identify what you want to achieve and highlight the purpose and aim of the session. Make sure that the proposed intervention is linked to an up to date assessment and care plan (or intervention plan).You also want to detail here specifically what evidence-based interventions you are using and link relevant theory to justify the work which is linked to the needs of those involved; such as age, learning diversity/needs, gender, religion etc.
4) Brief description of what took place
Evidence here how you have ‘checked in’ and how they presented and engaged with you throughout the session. You can do this by paraphrasing the work undertaken.
5) Identify any risks to self and/or others
Identify any heightened risks or vulnerabilities of those receiving the support. This could be as a result of the session or issues that are on-going. Here be sure to include emotional, safety and well-being presentation. Also, identify and include any external professionals involved in addressing risks/safeguarding concerns.
Detail anything you need to do following the session that promotes ‘short’ and/or ‘long’ terms changes for those receiving support. Remember, focus on where we want to go and work backwards in identifying what needs to be achieved. Identify if you need to seek guidance from management support following the session.
7) Next arranged session
This allows evidence to detail that you have pre-arranged the next session. If you can, detail here what the next session will focus on. But remember, intervention delivery must be linked to what has been highlighted within the assessment and planning stages.