M2 - Learner Manual

Most of the case notes that will be useful will be obtained from client interviewing. Thus, it is necessary to make clear notes, during and also following the conclusion of the interview, in order to advance the clients wishes to the practitioner and ensure the file contains all relevant information. It is important to present the information in a clear and concise manner.

Keeping a written record[1]

One of the most useful things a practitioner can do is to help the client write a detailed record of the whole story. It may not be appropriate to try to do this at the first interview, especially if they are distressed, but it is important to do it as soon as possible to make sure they don’t forget important details.

It may help to get them to provide other details of the day when the incident happened, what the weather was like? How did they get to the place where the incident occurred, did they drive? Who else was there? Questions like these will help the person remember the details of the incident.

When they describe the actual incident a practitioner must keep asking questions to fill in the detail. Who else was there then? Did they say anything?

When the whole story is written down, the practitioner should get the client to go over it again to see if they remember anything else.

When the practitioner has the full story, they can work through to see where the problems lie and begin to work out what information is needed and how the problems might be resolved.

Additionally, it is useful to keep a written record, as if a client complains about the practitioner or another colleagues conduct, there will be physical evidence of what actually occurred.

It is also important to keep file notes/case notes. For example if in court a practitioner is asked by the Magistrate the name of the client’s treating psychiatrist, then they are able to automatically check on the file note.