Mā te rongo, ka mōhio
Mā te mōhio, ka mārama
Mā te mārama, ka mātau
Mā te mātau, ka ora
From listening comes knowledge
From knowledge comes understanding
From understanding comes wisdom
From wisdom comes wellbeing
The whakataukī helps us take a Māori-centred position where we consider what to record, when to record and the language we use to preference certain perspectives and world views.
Recording is the responsibility of every public servant
Casenote recording is a professional responsibility that is guided by legislation, codes of conduct and professional obligations.
Recorded information needs a structure
Casenote headers are important and should indicate what the content is. This helps us locate information, especially if it relates to our statutory obligations – for example, 'Collaboration with service providers', 'Views of paternal whānau' or '2-yearly caregiver review'.
Every casenote should start with the:
- time (if needed)
- type of engagement (such as home visit, office visit, digital media – text or phone call)
- full names of everyone involved and their relationship to te tamaiti or rangatahi
- purpose of engagement.
Avoid recording information that is not purposeful or relevant.
We record verbatim when we want to capture the exact words that were used. For example, a child-focused interview could include the question and then the response of te tamaiti, word for word. When we record verbatim, we need to add a section that explains our understanding of the discussion.
Use headings and subheadings to structure the record into a logical format.
Information during a discussion doesn't flow in sequential order – we can re-order it when we put it into a casenote under key headings.
Preparation is the key. For example, before a visit to a tamaiti or rangatahi in care, we can consider the headings in the All About Me plan to help with our approach in our kōrero. This can then help us with how to capture the kōrero in our records.
Writing style can vary
We need to adjust our writing style to suit the purpose of the information that is being recorded, such as reports, casenotes, minutes from hui, referrals to community groups, court reports, All About Me plans, suicide screens or visits to tamariki in care:
- Casenotes are where we record who did what, when and where.
- Consults provide a record of the information we used to understand and prioritise our mahi, based on collective sense-making.
- Tuituia assessments and other screening tools record our analysis to help us to evidence decision-making.
- Tuituia reports, All About Me plans, family group conference plans and court plans record our agreed next steps. Plans should describe who agreed to do what and how we know it will be making a difference.
Check if a template is available – templates can help us meet the requirements stated in legislation or court and screening tool rules. Templates are in CYRAS.
Use the organisation's communication guidelines – they cover topics like plain language, common terms and avoiding or explaining jargon and acronyms.
We are succinct – there is no requirement to repeat recorded information – but we make sure that what we are writing will make sense to other readers, especially people who may be reading the record in the future.
We can write in the first person or third person, and we can address te tamaiti or rangatahi in our writing, depending on the purpose of the recording. Addressing te tamaiti or rangatahi is narrative and descriptive. It could be an appropriate style for a visit or when recording their All About Me plan. If te tamaiti or rangatahi were to request their file, this style might help them understand how decisions were made about them and what happened.
We clearly differentiate between facts, opinions and observations. Rather than recording 'you looked happy' (which is an opinion), the casenote could state that 'you had a big smile' (observation) and then 'you seemed happy and relaxed because...' (analysis).
Before committing words to a casenote, we test our bias. We can ask ourselves:
- Was the parent angry or were they frightened or shocked, which led to them shouting?
- Did they lie, or did they not trust me with their truth so they omitted information?
- Did they fail to follow up or was the plan unrealistic?
- Was he resistant to change or did he not understand what was required?
Describe behaviour rather than interpret it.
All opinions need to link to examples of fact.
Our analysis is strengthened when multiple sources inform our understanding.
Consider each casenote as a stand-alone page that has to make sense – include context and reasons that explain our decision-making.
Consider starting the casenote with the main message and the details of how we got there underneath. Casenotes can be structured like a well-written assignment.
The following examples are not full casenotes – not all sections have been filled out. The purpose of the examples is to show how the same information can be written in different ways. We have used italics after sentences to highlight facts and opinion (but this is not expected in your recording).
Recording hui ā-whānau using Te Toka Tūmoana
This example shows how a social worker has used the 8 guiding principles of Te Toka Tūmoana to record a whānau hui. The danger, harm or risk is not minimised, but the parents' mana is upheld and strengths are highlighted. The names and certain details have been changed to respect the privacy of the whānau. Note that the format (template) was developed by kaimahi using the Te Toka Tūmoana guidance – it is therefore not an official Oranga Tamariki template. It shows how kaimahi can be creative when writing casenotes but maintain policy requirements for recording our work.
Electronic and physical records
We record information about our mahi with tamariki, rangatahi, whānau or family, caregivers and victims of youth offending in either CYRAS (the Care and Protection, Youth Justice, Residential, Adoption System) or CGIS (the Caregiver Information System).
We save, scan or screenshot all documents, letters, plans written on a whiteboard, pictures, photos, post-it notes, texts or social media messages, and other information and load them into CYRAS or CGIS. The original records can be added to the physical (paper-based) file, as appropriate. We always explain who provided the information and for what purpose, so this is understood when others are reading the records – for example:
- Phone number or email address
- Full name and relationship to te tamaiti or rangatahi
- Purpose or summary
- Next steps
Insert or load the scanned document, or note that originals can be found in the paper-based file.
When photos are received, we consider the purpose of loading them into CYRAS. Alternatively, we enter a casenote that they have been received and are stored on the physical file.
If we share photos, we ensure that guardianship consent is recorded.
Summarising multiple contact attempts
Relational practice takes time. For example, we don't need to create a standalone casenote for each attempt to phone or visit a whānau or family – instead, we could create a casenote that summarises our mahi to date. The same can be done for multiple emails with different professionals.
The practice standard 'Keep accurate records' helps us decide what to record.
An affidavit is written evidence for court documents. It is a sworn or affirmed statement that is made on oath before a Justice of the Peace, registrar or solicitor. We observe the same rules about evidence given orally. Check that the content is:
- first hand, if possible
- written in the first person.
Use the template on CYRAS – the template complies with court rules about formatting, such as font, size and line spacing.
The way we structure the affidavit should help the reader understand the information and highlight critical information. We might use chronological order or have the most recent developments first, followed by the history. We also use headings, and number paragraphs and pages.
In addition, we:
- check the source information and ensure it's correct – it should not state that something is a fact if it is alleged
- can include historical information from CYRAS, even if we are not the author – however, be clear about the source of the information
- include all relevant information, especially when it doesn't support our application and is an alternative perspective
- introduce adults with their full name and then subsequently use Mr X or Mrs X or Ms X – not their first name
- can include 'exhibits', which is evidence to back up our statements – they are attached to the end of the affidavit and marked 'a', 'b', etc
- proofread the affidavit
- ask Legal Services to read it before it is sworn and filed in court.
We may be required to speak to our affidavit in court as a witness. We need to have sound knowledge of what we are writing about and ensure it is factual and respectful and that opinions can be evidenced as we may be cross-examined. We think about our use of language and how it can be interpreted by others.
For example: instead of saying 'XX behaviour has been really challenging for others to manage and she refuses to cooperate with her caregivers', we could write 'XX is really struggling with not being able to live at home. She is unhappy and often distressed and this is reflected in how she interacts with others and is understandably impacting on her relationship with her caregivers'.