Q-COMP

What are case notes?

Case notes record important details about an injured worker's rehabilitation and return to work program. They can be hand written for a paper file or created and stored electronically. Case notes should be started as soon as you're notified a worker has been injured. Case notes must be kept for each worker who is undertaking rehabilitation and should be kept in a secure location separate from the worker's personnel file. Case notes can record information not captured in incident or accident reports and they can be used to provide initial assessment of the need for rehabilitation.

Case notes can:

• supplement other records such as emails, suitable duties programs, medical certificates and reports
• provide details on factors affecting the outcome of workplace rehabilitation
• record details of a worker and employer's participation and progress towards their rehabilitation and return to work goals
• detail the need for any changes to the suitable duties program
• document information provided verbally by the worker, service providers and the treating doctor or specialist
• provide an explanation of how planned activities will help the worker return to work and document the outcomes of such activities.

Case notes assist the rehabilitation and return to work coordinator in remembering the details of each case and are useful in the event of a handover to another rehabilitation and return to work coordinator. Case notes may be used as evidence in the event of common law action taken by the worker or they may be audited to monitor compliance with state legislation and your organisational policy and procedures.

What should you include?

• The date of the case note
• The name and role of the person making the note
• The name of the contact, their position and title
• The manner and purpose of the contact
• A factual description of the event
• Details of information provided verbally
• The purpose of and reasons for any decision or action
• Details of the decision made, proposed action or action already taken
• A reference to a policy or procedure allowing the decision or action.

In your case notes, you're not just representing yourself. Case notes are legal documents representing your employer so ensure they are appropriate by:

• recording facts only - behaviour you observed and statements you heard - don't make a diagnosis
• recording facts accurately and completely
• never including judgmental opinions, stereotypical comments, or any offensive statements
• never making comments you couldn't defend in a court of law
• labelling any 'opinion' as an opinion and not factual evidence
• using clear, simple, concise language, including professional terminology if appropriate
• not using slang or street language, clichés, or jargon
• not making sarcastic comments
• avoiding metaphors or similes - just say what you mean directly
• not commenting on details irrelevant to the worker's participation in rehabilitation and return to work activities.