Introduction
This topic is about writing casenotes. Each casenote should have:
- a clear purpose
- an appropriate title/subtitle
- all relevant details.
Responsibility
All staff with access to IOMS can write, access and read casenotes.
Note: Where one staff member enters a casenote prepared by another staff member the entry must contain the name of the staff member it was prepared for. The 'author' field in IOMS records the person who created the note.
Content
Casenotes should be:
- clear, concise and accurate
- detailed
- impartial
- professional
- understandable to a third party
- relevant to offender management
- free from spelling and typing errors
- in active language
Title and subtitles
Each casenote entry has a title and a subtitle, which can be selected from a drop-down menu, depending on the purpose.
Example: A service manager conducting an OWR check would select the title 'Offender Warning Register' and the subtitle 'Manager Check'.
Reference: For more information, see the Quick Reference Guide to Casenotes under CPPS Operations Manual>Training> IOMS Training Materials.
Recording multiple topics
When recording a casenote that covers multiple events, each event should be recorded under the appropriate title/subtitle.
This will enable casenotes to be easily sorted and accessed for future reference.
What to record
Casenotes can involve a number of elements. Use the table below when considering what to write in a casenote, including some or all of the information that relates to the following elements.
| When considering... |
then record... |
| an event (including report ins) |
-
time, date and location
-
who was involved eg, support person/s who attended
-
issues/risks presenting
-
purpose
-
outcome
-
details of any follow-up actions
-
updates against offender plans/objectives/referrals
-
summary of any casework undertaken at session
-
next report in date
-
consultation with others (external/internal)
-
any presenting risk identified.
Note: IOMS will automatically stamp the note with the time and date you enter it.
|
| action or follow up |
- details about what was done eg, a discussion about an offender’s non-compliance with a service provider
- when was the action taken
- by whom.
When recording follow-up action required by the writer or another person include details about what action is required, who is responsible and when it will be taken.
|
| documents |
-
the document type, such as letter, email, form, report
-
copied and pasted information from the document, including the details of the writer and when it was received
-
a summary of the document’s content, if the document has details relating to other people or issues that are not relevant to the offender.
Note: Consider whether the document should be copied and pasted into casenotes, or if the information is available elsewhere in IOMS.
|
| liaising with other people |
|
| compliance |
- details of compliance including non-compliance
- whether information is self-reported
- action taken to confirm self-reported information.
|
| a decision |
- the decision that was made
- who made it when it was made
- what the expected outcome should be.
- Any exceptions from manual standards eg, a lower reporting regime, should also include:
- why the decision was made
- who made it
- the expected outcome recorded in casenotes
- any manager approval, and the name of the manager.
|
| risks and concerns |
-
detail of the escalation of risk
-
any concerns around negative patterns of thoughts and behaviour
-
any evidence including observations and hearsay evidence
- details of risk management.
|
| further offender warning system casenotes |
- details of the OWR assessment and scoring
- any police notification of HRX/extended supervision/life parole status
- service managers’ OWR checks, including any specific remedial action required and the area this is required
- justification for removing an offender from the OWR.
|
Do not include
Casenotes should not include:
- local acronyms, codes or shorthand
- abbreviated terms
- colloquialisms, slang or inappropriate language
- reference to names without indicating who this is (eg, family/whanau)
- disparaging comments/opinions about the offender or others
- information that is not relevant to offender management
- information about other offenders unless there is a clear link (eg, non-association/justified risk concern)
- post-dated notes or reminders.
Automatically generated casenotes
There are five occasions where casenotes are automatically generated from other IOMS screens. There are free text boxes in each of these screen where extra notes can be added.
The five screens that automatically generate a casenote are:
- contacts
- approved absences
- report in
- non-compliance
- offender warning register.
