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Recording Notes

Documenting your work is essential for maintaining continuity of care and ensuring all team members have access to important client information.

📝 Why Notes Matter​

Good note-taking helps:

  • Track client history - See what services have been provided
  • Maintain continuity - Other staff can pick up where you left off
  • Document outcomes - Prove impact and measure success
  • Legal protection - Create records of interactions
  • Improve service - Identify patterns and gaps in service delivery

✍️ How to Add a Note​

Quick Steps​

  1. Click "Add Note" in the task or conversation view
  2. Type your notes in the provided field
  3. Click "Save"
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Screenshot showing the "Add Note" button and note field will be added here.

When to Add Notes​

Add notes:

  • ✅ After every client interaction (call, chat, email, etc.)
  • ✅ When you assign or transfer a task (explain why)
  • ✅ When you take an action (scheduled appointment, sent information, etc.)
  • ✅ When important information is shared (change in circumstances, new needs, etc.)
  • ✅ At the end of each workday (summarize any pending items)

📋 What to Include in Your Notes​

Essential Information​

Every note should include:

  1. Date and Time (usually auto-populated)
  2. What happened - Brief summary of the interaction
  3. What you did - Actions you took
  4. Next steps - What needs to happen next
  5. Who's responsible - Who needs to do the next action

Example Note Structure​

Client called regarding transportation assistance for medical appointment.

Actions taken:
- Verified appointment date: March 15, 2:00 PM
- Confirmed pickup address: 123 Main St
- Scheduled transportation through ABC Transit
- Confirmation #: TR-12345

Next steps:
- Client will receive confirmation call 24 hours before pickup
- Follow up on March 16 to confirm appointment was kept

Status: Resolved

✅ Best Practices​

Be Clear and Concise​

  • ✅ Use simple, professional language
  • ✅ State facts, not opinions
  • ✅ Be specific (dates, times, names)
  • ❌ Avoid jargon or abbreviations others might not understand

Be Professional​

  • ✅ Focus on the service interaction
  • ✅ Respect client privacy and dignity
  • ❌ Don't include personal judgments or unnecessary personal details
  • ❌ Don't use stigmatizing language

Be Timely​

  • ✅ Add notes immediately after interactions
  • ✅ Don't wait until end of day when details fade
  • ✅ Update notes if situation changes

Be Thorough​

  • ✅ Include enough detail for someone else to understand
  • ✅ Document both successful and unsuccessful attempts
  • ✅ Note any barriers or challenges encountered

🔒 Privacy and Confidentiality​

Remember:​

  • 🔐 Notes are part of the client record - treat them as confidential
  • 🔐 Follow HIPAA and privacy policies - only include necessary information
  • 🔐 Don't share client information outside of Connie unless authorized
  • 🔐 Be mindful of sensitive information - use appropriate discretion

📊 Note Categories (If Available)​

Some organizations use note categories to organize information:

  • Contact Note - Client interaction
  • Service Note - Service provided
  • Referral Note - Referral made or received
  • Follow-Up Note - Status update
  • Administrative Note - Internal communication
info

Check with your supervisor about which note categories your organization uses.

💡 Quick Tips​

For Phone Calls​

Document:

  • Who called whom
  • Reason for call
  • Information shared
  • Commitments made
  • Next contact scheduled (if applicable)

For Referrals​

Document:

  • Organization referred to
  • Services requested
  • Information shared with client
  • Client consent obtained
  • Referral confirmation received

For Transfers​

Document:

  • Why you transferred
  • Who you transferred to
  • What information you shared
  • Current status of client need

For Unsuccessful Contacts​

Document:

  • Method of contact attempted
  • Date and time of attempt
  • Plan for next attempt

⚠️ Common Mistakes to Avoid​

❌ Don't Do This✅ Do This Instead
"Client was difficult""Client expressed frustration regarding wait time"
"Helped client with stuff""Provided information about food pantry locations and hours"
"Same as last time""Delivered weekly meal delivery. Client reported satisfaction with service."
No note at allAny note is better than none

🔍 Reviewing Your Notes​

Periodically review your notes to:

  • Ensure completeness
  • Check for follow-up items
  • Verify accuracy
  • Improve your documentation skills

📚 Organization-Specific Guidelines​

caution

Always follow your organization's specific documentation policies and procedures. This guide provides general best practices, but your organization may have additional requirements.

Check with your supervisor about:

  • Required note frequency
  • Mandatory fields
  • Note review processes
  • Documentation audits
  • Retention policies

Next: Learn about Troubleshooting common issues

Questions? Check our FAQ or Get Support