Case Notes

Case notes are crucial in evidencing and documenting your time spent working with our tangata whaiora.

Good case notes:

• describe the activity and interactions of that session

• any observations that may be worth noting

• are objective as possible

• raise any concerns

• have a plan for next session

• are to the point

• able to be understood by the rangatahi/whānau

Case notes should be entered into noted as soon as possible, preferably at the end of each day. Case notes should include:

• any related reports or files

• any media (photos, videos etc)

• screenshots of conversations (via texts, emails etc)

• any communications with external professionals

• any attempted contact, missed sessions or changed plans

The outcomes assessment should be done when a tangata whaiora starts in the service and when they leave. This assessment is a good opportunity to gauge where the tangata whaiora are and can be used to inform the Tangata Whaiora Plan.

Noted is able to capture what Pou we are supporting or working towards with our tangata whaiora so we have data around what we do well and what we need to work on. Learn more about our 6 pou here.

Your dashboard is where you will see all unsigned records, any reminders you have set for your tangata whaiora and where you can search directly for a tangata whaiora. 

The groups feature is good to use when you are engaging with multiple tangata whaiora, especially on reoccurring occasions. 

After creating a record and filling out the required information, you must sign your records so they are locked. If you have accidently created a record under the wrong tangata whaiora please us know. 

Every tangata whaiora in our services should have a plan. Essentially the tangata whaiora plan is a map of where they are, what their goals are and how they are going to achieve them. These plans only need to be updated when something in the plan has been achieved, changed or updated. This should be the blueprint for all your interactions with the tangata whaiora.

When you go to the client overview page (after you have selected the tangata whaiora to view) you will see what are called tracking forms. These forms are able to edited directly from the overview page or by going into records and the clicking on the drop down in the top left under the tangata whaioras name. 

On the clients page you are able to search for any of your tangata whaiora, as well as create custom search lists that apply to you and work load. You will only have access to the records and overview page of the tangata whaiora in your team.