Documentation - General Guidelines
The purpose of the Case Narrative Writing Guidelines is to provide Employment Services Workers with basic rules and guidelines for case narrative writing and to identify the required case narrative entries.
- Keep in mind who your reading audience will be:
Reminder: Clients have the right to review entire case record, including documentation.
- Site facts and relevant information only. Indicate how the information was obtained including how and when.
- Clarity is essential. Organize and present information in a manner that makes sense and is easily understood by the reader including how and when.
- Keep the narrative free of subjective statements.
- Make sure narrative is accurate and that it does not conflict with other narrative entries or other information in case. Explain if conflicting entries are entered.
- When referring to a staff member or service provider, use the person's full name/title, worker number, phone number/extension and include the name of the person's agency.
- Record the date of the entry in the left-hand margin. Enter your name and worker number at the end of the entry. If you are the O.D. (Officer of the day), indicate this in the entry after your worker number.
- Document all case activity immediately after it occurs.
Related Topics
Documentation - Purpose of Thorough Documentation
Documentation - Maintain Case Comments Window
Documentation - Standard Abbreviation Guide
Documentation - Examples of Types of Case Narrative Entries