This procedure deals with the requirements for recording case notes on CRIS and in the young person's file.

 

When to use this procedure

When supervising a young person subject to a youth justice court order.

 

What else you need to know

Make sure you have read and understood the following procedures:

 

Practice context and legislation

  • Recording and maintaining accurate information contributes to many key functions.
  • Keeping case notes:
    • is important for professional and legal accountability
    • provides a record of court order requirements, case management and service planning
    • records critical historical information
    • clarifies and interprets complex information
    • documents the rationale behind key decisions
    • provides a record of all contacts, attempts to contact and events related to a young person
    • helps identify patterns in behaviour and service responses
    • provides an archival record of events that can be accessed by the young person, their family, new workers and others as appropriate
    • supports continuity of service delivery between workers and services
    • provides the basis of professional reports
    • identifies areas that require follow up/action.
  • The structure and content of case notes depend on the purpose, nature and details of the event.
  • Case notes must be professional and concise.
  • The purpose of the case note, and its relevance to case management, must be written clearly and in a manner that will withstand the scrutiny of case file audits and freedom of information access.
  • Through the Client Relationship Information System (CRIS), case notes can be exchanged between all areas of the youth justice system, including area youth justice services, youth justice centres, the Youth Parole and Residential Boards and Central After Hours Assessment and Bail Placement Service. CRIS can also  share certain information across wider departmental programs outside youth justice.
  • All information relating to young people, including case notes, is written and stored on CRIS.
  • Case notes must be recorded in accordance with departmental privacy and Freedom of Information guidelines.
  • Youth justice files are legal documents and can be subject to subpoena orders by a court, Freedom of Information requests or requests from the Ombudsman for any purpose.
  • Release of information for any of these purposes is determined in accordance with the relevant legislation and in consultation with the legal services branch.
  • Case notes provide an opportunity to examine the strengths, weaknesses and areas of improvement of past case management and contribute to practice knowledge for future decision makers.
  • The Information Privacy Act 2000 and the Health Records Act 2001 regulates the ways that personal and health information, can be collected, used, stored and disclosed.
 

Roles and key tasks

Case manager

  • Record detailed and accurate case notes on CRIS, ensuring that they are up to date so that case managers are accountable for their case practice.
  • Complete a youth justice case worker file audit.

Team leader / team manager

  • Complete file audits to ensure case notes are up to date, accurate and reflect the young person's current situation.
 

The procedure in detail

Confidentiality

Only document information relevant to case management and youth justice's mandate.

Privacy

Record in a clearly identifiable case note that the young person has signed the CRIS privacy consent form and store the hard copy on the paper file.

Case notes should be specific to the young person and, as far as possible, not make reference to other young people.

Paper files

When a new young person is created in CRIS a paper file number is generated on the departmental record keeping program, Total Records Information Management (TRIM).

The allocated youth justice worker should create a paper file to store original documents and paper records.

All original hardcopies of documents including hand written notes, letters, faxes, other professional reports and copies of youth justice court reports are to be placed on the paper file with a CRIS case note created to advise where the information can be accessed.

If possible, these documents should be scanned and attached to a relevant CRIS case note.

Hand written file notes may be stored on the paper file until such time that a record has been entered on CRIS.

Security of information

Reasonable steps must be taken to protect a young person's personal and health information from misuse, loss, unauthorised access, modification or unauthorised disclosure.

To ensure information (hardcopy or electronic) is kept secure:

  • store hardcopy files in secure filing cabinets
  • do not leave information about young people on desktops, whiteboards, fax or photocopy machines
  • secure computer access to electronic information when not in use
  • if removed from the office, place hardcopy information in a briefcase, satchel or other suitable container
  • do not discuss information about a young person in public or where it can be overheard by unauthorised people
  • destroy or de-identify obsolete copies of information/reports
  • ensure compliance with departmental and local practice guidelines relating to the use of portable storage devices. Portable storage devices that contain identifying information must be password protected and stored in a secure place.

Accountable case note recording

Preparation of case notes requires:

  • objective observation and monitoring of young people
  • analysis of information
  • professional judgement
  • clear documentation differentiating between facts, observations and professional assessment.

If an appointment or activity with a young person is held with more than one youth justice worker, the content of the case note must be agreed upon by all workers.

Case note approval can be actioned via CRIS. If a case note indicates a consultation has occurred with a team leader, the file note is to be approved by the team leader in CRIS via the worklist function.

If a joint appointment or activity is undertaken by a youth justice worker and a worker from a community service organisation, the youth justice worker must enter case notes on CRIS.

Case file audits

As part of supervision, case files, including case notes, are routinely audited by team leaders.

Content of case notes

Each case note must be entered in the appropriate CRIS field and include:

  • date
  • author
  • subject title that clearly identifies what is contained in the note
  • source of information
  • reference to any attachments.

Case notes may also contain the following information:

  • the purpose or outcome of an event
  • key issues discussed or arising
  • approvals and follow up actions
  • a young person's presentation, behaviour and level of engagement
  • changes to risk assessment or a young person's general wellbeing
  • rationale behind decisions made
  • actions or tasks taken or required
  • information from other professionals
  • referrals made and outcomes
  • other workers or professionals present.

Formulating case notes

Well-written case notes are easy to read and provide vital information quickly.

  • Use language that is clear and easy to understand.
  • Construct simple and concise sentences.
  • Avoid long paragraphs that are overly descriptive.
  • Ensure all information is relevant and factual.
  • Where possible record information sequentially.
  • Limit use of jargon and acronyms.
  • Identify other people referred to by their formal name and role.

The length of a case note is guided by the content or type of event.

A case note reporting a simple event will only be one or two lines.

Case notes documenting significant events will be longer.

On completing a case note, re-read it and consider how clear and useful the content will be to another professional reading it for information about the young person or case.

Use CRIS functionality to check spelling and grammar.

Documents stored on the young person's file

The following documents must be held on the CRIS or paper file.

If held on the paper file a note to that effect must be entered on CRIS:

  • police summaries
  • youth justice reports
  • court orders
  • other court documents
  • incident reports
  • health reports, including psychological reports
  • any assessment or reports completed by other professionals
  • signed warnings
  • reports from community service organisations
  • signed Client Service Plan
  • signed Client Assessment and Plan
  • Changing Habits and Reaching Targets program plan and feedback
  • media related to young person
  • file audit documentation
  • any published material relating to the young person
  • disability services reports
  • child protection reports (note where the report is internal and not for release)
  • custodial services reports
  • any complaints or other communication from the young person or family member
  • emails and text messages about the young person – these should be copied and pasted into a CRIS case note
  • school reports.

Alerts

Alerts on CRIS files let staff know about existing or potential risks when working with a young person.

The CRIS alerts system gives staff access to crucial information for risk assessment, case management and supervision.

Alerts will be considered as part of intake procedures in community based services, admissions in centre-based services and during assessment and planning.

For more information on alerts, see the CRIS business practice guidelines.

Create a case note in CRIS when an alert has been activated and identify the reasons for the alert.

Sharing information

If a young person is also involved with child protection and/or disability services, use the joint protocols for information sharing between programs, services or agencies.

Timeliness

Best practice is to ensure that case notes are recorded on CRIS within two days of the event to which they refer.

If this is not possible, case notes must be finalised in CRIS within two weeks after the event to which they refer.

Youth justice workers must develop a management plan in conjunction with their team leader to manage any case recording backlog.

This may include strict priority setting for high-risk cases.

Further information

For further information relating to case note recording seek procedural advice from:

  • your team leader
  • Department of Human Services Legal Services Branch
  • your area's freedom of information unit.

Case closure

When closing a case, ensure all case notes are finalised in CRIS, and the handover or closure check completed.

Any information received by youth justice after the young person's order is completed must be case noted onto CRIS at the closure phase.

The paper file is forwarded to the youth justice administrative officer or team leader who will record the file as closed in TRIM and forward it to archives.

Recording information after an order has expired

Youth Justice may record information about a young person after case closure and the expiration of a statutory order, in certain instances including:

  • when youth justice has continued to assist a young person
  • when there is likely future involvement with youth justice or child protection, or
  • in the event of the death of a young person.

The ongoing information must be treated in accordance with existing youth justice information collection procedures and the Children, Youth and Families Act 2005. The Information Privacy Act 2000, the Health Records Act 2001 and the Public Records Act 1973 must be applied to the collection of that information.

CRIS functionality allows for workers to continue to enter case notes on a young person's file even after all administrative closure tasks have been completed.