Training – Case Notes: 04 March, 2024

My name is Lucy Wise and I am a Clinical Psychologist with over 20 years experience. I am an AHPRA Board Approved Supervisor and I have also had the privilege of being asked to be on the Performance Assessment Team for AHPRA. These experiences have given me the opportunity to look at what clinicians are assessed against for good and bad performance and even more terrifying to observe how we use case notes to record our sessions. I have seen the good bad and ugly! Given the amount of time we spend writing and recording our sessions there is a lack of information about what is expected. The quality of our case notes is one of our key lines of defence in the face of a complaint.

As a result I have made the decision to devise a training that incorporates all that I have learned into a training that hopefully provides some guidance for an area of our practice where there is typically a paucity of information and a lack of a “gold” standard. This training is designed to provide some working examples and some key information about clinical case notes, how to construct them and what they should contain. I hope this workshop gives you a bit more confidence in how to write and record your information.