Guidance on Clinical Notes| Workplace, Community and Member of the Public Pathways.

Background

Clinical notes have a role to play in our services.

They are owned by Atrium but should be prepared with the client so that they own their care. There should be no surprises and they can also be a resource to the wider professional network with client consent and ensure the practitioner’s protection because they illuminate how the work has been done with attention to due processes to keep the client safer and in their best interest (evidence –based practice).

History of notes – read them.

Is this the first episode of care? Have you read the previous notes to get an understanding of the history with help of the client, to understand more about their patterns of wellbeing and risk? Have there been historic risk markers through CORE assessments or flags raised on CORE? Do discuss flag markers on CORE with your supervisor.

What do practitioners write?

You write collaboratively with the client in a format below. No more than 8 lines as a guide.

• Client’s risk assessment and wellbeing; safety planning amendments and any actions.
• If scores indicate poor wellbeing, show you have opened up a risk assessment conversation and the reasons for your judgement of risk/no risk eg. history, protective factors and support and safety plan in place?  Indicate that safety planning undertaken for poor wellbeing scores and actions taken/consent. Have you used the best CORE measure for poor scores eg. CORE 34 for Risk?
• Home work if appropriate reviewed and set; resources sent
• What client took from the session and consideration of progress towards goals. Changes or additions to formulation.
• Plans for next session
• Date and time for next session and any admin arrangements eg. approval for next session from employer.
• Any actions in between session eg. speak to supervisor safeguarding risk discussion
• Other as relevant.

Notes will need to be extended by closure. A summary of risk, engagement with help and plans in place is important in the last session and whom in the professional network has been informed of the closure of the work. See Discharge policy and guidance on CORE.

When can we share notes?

Only ever share notes with pathway team consent after pathway team have checked with clinical supervisor. Forensic routes- never share notes and refer enquiries to Forensic services not affirming that we have ever worked with client or that they have been in prison. All requests for notes should go through the office and you will be advised. For safeguarding concerns and professional partner information sharing on specific plans or safety plans, check with your supervisor and the client where possible before sharing client information.