How should case notes be entered and what standards should be followed?

How should case notes be entered and what standards should be followed?

• A. Timely, factual, non-judgmental, include timestamps, author, and source
• B. Enter with opinions
• C. Only after formal review
• D. Whenever comfortable

Answer: (A)

Case notes should be entered promptly and be based on observed facts or direct information, not personal opinions. They must be factual and non-judgmental, describing what happened, when and where it occurred, who was involved, and any actions taken or planned. Each entry should include a timestamp to establish exact timing, identify the author who recorded it, and note the source of the information (such as interviews, documents, or direct observations). This combination ensures accuracy, accountability, and a clear, traceable record for others reviewing the case. Delaying entries or adding opinions would undermine reliability and objectivity, so notes shouldn’t wait for formal review or be entered only when fully convenient.

Case notes should be entered promptly and be based on observed facts or direct information, not personal opinions. They must be factual and non-judgmental, describing what happened, when and where it occurred, who was involved, and any actions taken or planned. Each entry should include a timestamp to establish exact timing, identify the author who recorded it, and note the source of the information (such as interviews, documents, or direct observations). This combination ensures accuracy, accountability, and a clear, traceable record for others reviewing the case. Delaying entries or adding opinions would undermine reliability and objectivity, so notes shouldn’t wait for formal review or be entered only when fully convenient.