Case recording

Case recording is an important aspect of statutory child protection practice. Case recording has a number of important functions, including to:

• enable critical historical information to form a key part of risk assessment
• structure and clarify complex information and interpretation
• articulate the assessment and rationale behind case decisions
• provide a record of all contacts and events related to a client, case management and case planning processes
• ensure that important information can be retrieved and understood
• fulfill professional and legal accountabilities
• provide an archival record of events in the life of a child that can be assessed by the child, family, new practitioners and others when needed
• assist in identification of patterns in client behaviour and service response
• identify the success or failure of past interventions for future decision-makers
• form the basis of formal reports.

The following principles apply to all case recording:

• When determining whether a decision or action is in the best interests of the child, always consider the need to protect the child from harm, the need to protect their rights and the need to promote their development (taking into account their age, gender and stage of development).
• Case notes should be recorded in accordance with privacy and freedom of information guidelines.
• Only relevant information should be recorded.
• Clients, their families, carers (where relevant) and professionals should be advised of the purpose of collecting information, and the purposes for which it may be used.
• Clients and their families have a right to correct and update inaccurate information recorded about them.
• Personal information should be stored securely.
• Release of information should be determined in accordance with the CYFA, Child Information Sharing Scheme, Family Violence Information Sharing Scheme and privacy laws.

See Information sharing in child protection practice.

Public Records Act

The Public Records Act 1973 sets out requirements for the retention of public records.

Freedom of Information Act

The Freedom of Information Act 1982 provides members of the public with a right to apply for access to information held by the department about them or members of their family, including child protection files.

A paper file will be created if paper records or handwritten notes have been created and need to be stored. If a paper record is created, any sibling who is a client should have their own separate paper file. A brief record should be entered on the electronic file for every record added to the paper file, for example, the type of document, author and date received.

All case notes must contain:

• the purpose and outcome of the event
• key issues discussed or arising
• changes to risk assessment or wellbeing
• decisions made
• action taken or required, and;
• reference to any other relevant information on either the electronic or the paper file.

The following case documents will be recorded contemporaneously, that is, as soon as possible and within 24 hours or the next working day:

• intake record  
• after hours records  
• first home visit  
• client visit case note
• investigation of new allegations of abuse  
• disclosure interviews (any additional material such as drawings, body charts are placed on the paper file)
• court action.

All other case notes, documents and significant decisions must be recorded as soon as practicable and must identify the author's name and role.

The record of any joint home visit or interview should be read and agreed to by both practitioners. Prior to the home visit or interview the two practitioners should decide who will be taking the primary notes.

Where joint activity is undertaken by a child protection practitioner and a community agency practitioner it is the responsibility of child protection to take the case notes and complete the child protection record of the activity.

CRIS case notes are structured to include date, practitioner name, case note heading, time, key decision indicator, a summary section, a details section, a case plan decision section, and a safety, development and wellbeing section, related to risk and needs assessment.

Handwritten records should be retained on the paper file unless a contemporaneous record has been made on CRIS. Handwritten notes may be added to, highlighted or elaborated upon to ensure that the record contains all relevant information. Additions to handwritten notes should be distinguishable and dated. A child protection practitioner may not change a record made by another practitioner.

Information received by child protection after a case has been closed is recorded as a case note and attached to the closure phase of the last intake unless it contains a new allegation, in which case the allegation will be treated as a new report.

Specific procedures exist for recording client deaths and information and assessment regarding SIDS (sudden infant death syndrome). It is important to read the advice in relation to these specific situations and follow the procedures.

The following information is recorded on the child's CRIS or paper file (if held on paper file a note to that effect must be entered on CRIS):

• client incidents, incident investigations and reviews managed through the Client Incident Management System (CIMS) (including those completed by either child protection or a CSO), or the Reportable Conduct Scheme (RCS, when applicable)
• family violence reports from police
• complaints by the child or parent in relation to the case
• formal care reviews 
• any emails
• medical reports  
• assessment reports 
• reports from CSOs
• birth certificates

The following specific recording requirements apply:

• team manager/case planner must record case planning decisions
• appropriate line manager must record internal review (s. 331,CYFA) decisions
• practice leader or principal practitioner to record consultation regarding re-classifying a case from infant intensive response to infant response.

Client Visit Case Note

Client visit case note must be completed for every visit involving a child known to  child protection, except for the first visit, which should be recorded in the First Visit Date/Time fields on the Investigation Phase page in CRIS, as well as using the First Visit Document.

This case note has capacity to be saved across a sibling group, where relevant.

The client visit case note must be used for any visit (planned or unplanned) to the client (noting child protection’s client is the child), irrespective of whether the visit proceeded, the client was present or if entry to the home was refused. The client visit case note should also capture any client that was unexpectedly present at the visit.

The client visit case note contains an ‘Other Participants’ grid. This grid must be used to record each client in the sibling group (subject to current child protection intervention) who was present, or who was reasonably expected to be present. This allows for the nature of contact for each client to be recorded against them as an individual.

Where the visit is to a carer/ parent/ guardian and there is no intention of engaging with the client, a general case note is to be completed.

See Client visit policy for further information.

Recording specialist practitioner consultation advice and recommendations

All case related consultations with a specialist practitioner must be recorded on the client file. This provides accountability to the client and the organisation for the assessment and intervention.

Creating a record of the consultation is critical to the purpose, actions and recommendations arising from the consultation being accurately reflected, available to guide implementation of the actions, and inform future work.

The specialist practitioner who provides the consultation is to record it on the client CRIS file including outcomes within one week of the consultation occurring.

After a consultation has occurred, the direction and guidance provided is to be referenced in records of future assessment and decision making where relevant.

By exception, where a consultation is unplanned or occurs remotely over the phone for example, the record of consultation is to be recorded by the child protection practitioner where agreed during consultation. The specialist practitioner is responsible for checking and ensuring the consultation is accurately recorded on the client file.

The specialist practitioner must always record:

• the date, purpose and outcome of the consultation
• key issues discussed
• decisions made
• allocation of responsibility for specific follow up actions.

CRIS naming conventions for recording case consultations

There are two important naming conventions to consider when creating a CRIS record of a consultation with a specialist practitioner.

Firstly, case notes in CRIS require the selection of a category type and there are four specific category types that pertain to principal practitioners (see below).

The second naming convention relates to standardised case note subject headings for all specialist practitioner consultations or activity in order to easily identify all records of consultations. Case note subject headings are free text fields and must clearly identify the specific specialist practitioner that has been consulted and a summary of the case note intent.

Subject headings for records of specialist practitioner consultations must use one of the following naming conventions:

• Principal practitioner consultation
• Principal practitioner consultation: infant response decision
• Principal practitioner activity
• Principal practitioner RSO consultation
• Practice leader consultation: infant response decision
• Practice leader consultation
• Practice leader activity

Note: For Chief Practitioner consultation, the principal practitioner naming conventions are to be applied.

Case notes created using these conventions will clearly identify records of the specialist practitioner consultation or involvement.

Chief Practitioner or principal practitioner

The record of a consultation with a principal practitioner (or the Chief Practitioner) must be created using the most relevant drop-down category available to accurately reflect the purpose of the consultation. The four categories are:

1. Principal Practitioner Consult: This refers to consultation between the primary child protection practitioner and a principal practitioner and includes in person or telephone discussions.
2. Principal Practitioner Consult – Convicted or Registered Sex Offender: This refers to a consultation between a child protection practitioner and principal practitioner regarding a convicted or registered sex offender. When consideration is being given to closing a report about a child in contact with a sex offender at intake or anytime during child protection involvement, the decision for closure must be reviewed by the team manager in consultation with a divisional principal practitioner. Decisions endorsing closure must be documented by the principal practitioner.
3. Principal Practitioner Review: this includes recording activity such as case reviews undertaken by a principal practitioner and report writing. It refers to work undertaken to review case practice, case management, or a case plan. The review might result in case advice or direction being provided, practice or planning recommendations or a written report.
4. Principal Practitioner Activity: this refers to principal practitioner activity that involves direct work with a practitioner to support, assist or lead case practice, case management, or case planning. Such activity might include attendance at court, leading or assisting the development of assessments or case plans, direct contact with the family, and leading or assisting the development of collaborative relationships within the child's family network. It might also include attendance at or facilitation of professionals meetings or care team meetings.

Practice leader

The record of consultation with a practice leader must use the most relevant drop-down category available to accurately reflect the purpose of the consultation and include the relevant subject heading. CRIS does not provide distinct case note categories to record contact with practice leaders. The consultation is to be recorded using current case note functionality within CRIS.

Accountability and accuracy

Practitioners should be able to explain and verify their case records and assessments to others. Case notes should not be overly descriptive and need to distinguish between fact and professional judgement.

Detailed recording

At times a very detailed record of events or an interview is needed (such as a disclosure interview and responses from parents regarding allegations of abuse). When taking detailed notes or recording interviews, clarify if necessary with the interviewer for accuracy to avoid inconsistencies.

Recording content and style

The structure and content of case recording depends on the purpose, nature and details of the event. Case notes should be professional, concise, not overly descriptive, the purpose of the record and relevance to case management should be clear and should be written in a manner that will stand scrutiny.

Generally, concise dot point lists with an appropriate lead-in phase or introduction are preferable to narrative writing.

Use of previously recorded information

Auto populated information on the electronic file (that is, information that ‘drops down’ into standard formats such as court reports, intake documents, case closures, client details) can save valuable time. However, the danger is that the information may not be accurate or current and therefore not a true representation of the facts. Alternatively its automatic inclusion in certain documents may pose a risk to the safety of a person. Confirm that all information on the electronic file is current and correct. Review auto populated information and remove if its inclusion in the document would result in an inaccurate record.

Managing backlog

A child protection practitioner must develop a management plan, in conjunction with their supervisor, to manage any case recording in a timely way and avoid having a backlog. Strategies include making case notes in situ where suitable to the circumstance, and information security and technology permit, setting aside time each day for case recording, and may include prioritising complex and high risk cases, including infant intensive response cases.

• Information sharing in child protection practice
• Consultation with specialist practitioners
• Client visit policy
• Client Incident Management System (CIMS) policy
• Client Incident Management System (CIMS) - Advice
• Allegations of harm to clients in care - Client Incident Management System (CIMS) procedure 
• CIMS policy and guidance – providers’ page https://providers.dffh.vic.gov.au/cims
• Reportable conduct scheme