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Page URL: https://practice.orangatamariki.govt.nz/previous-practice-centre/policy/caring-for-children-and-young-people/resources/recording-a-visit-with-a-child-in-care-sarahs-casenote/
Printed: 22/10/2019
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Recording a visit with a child in care: Sarah's casenote

Recording information in a way that keeps children and young people at the forefront of our decision-making is key to achieving successful outcomes for them.

Below is a best practice example of a child-centred 'visit with child in care' casenote.

Note: Names, places and identifiable information have been changed to protect privacy.


Name of child: Sarah Simmons

Age of child: 14 months

Date/time of visit: 22 August 2011, 2pm

Location of visit: Mary’s (caregiver) house, 11 Spring Road, Auckland

Observations

How is the child/young person presenting? Make sure that you know the developmental stage and abilities of the child that you are visiting so that you can identify any gaps in their development.

You had not met me before so you were quite suspicious and clung onto Mary for a wee while. I sat on the sofa and after a while you became quite curious about me. You walked up to me unaided and placed your hands on my lap. You looked at me with a huge grin. You have dimples.

I was wearing a bead necklace and you were fascinated by this. You played with my necklace for a few seconds and then took off quite quickly to the other end of the room. You stopped suddenly, turned around and ran quickly back to me. You were laughing when you threw yourself at me. I lifted you and gave you a cuddle. You liked that.

I watched you play with some building blocks. You tipped them out of their container and then picked them up one by one and put them back into the container. You were concentrating really hard on this activity.

Something else then got your attention – a metal pot lid lying next to the television. Mary told me it is the only thing in her kitchen that she lets you play with. You really like the lid and I watched you wave it around and hit the carpet with it.

You smiled and laughed almost the entire time I was at Mary’s house. Mary said you can’t talk yet, apart from being able to say one word (mama) but you do make lots of noise (i.e. babbling) when you get excited.

Child’s views

Talk with the child on their own to understand their worldview. Was the child seen alone? What was important for them to tell you? Was there anything we needed to talk with them about? How is the child presenting? Is contact with family meeting the child’s needs? How is their relationship with the caregiver?

You have not yet had contact with your mum and dad because I do not know where they are living right now. I do know it is really important for you to see them and other family members, and I have arranged a big meeting with some of your family at the end of the week (25 August) to talk about a whole lot of things including how we can make contact between you and your family happen safely and as soon as possible.

You seem to have become very attached to Mary in the five days you have been staying with her. I notice that you look around for Mary when you don’t immediately have a clear view of her, and when you make eye contact with Mary a big grin appears on your face and you laugh. I also noticed when I was getting ready to leave and Mary was holding you that when Mary tried to pass you over to me for a goodbye hug you pushed yourself away from me and clung to Mary.

Caregiver’s views

What is happening for the child and what are the successes and challenges? Any needs identified?

Mary is really enjoying looking after you, and thinks you are a very smart and inquisitive little girl. You are sleeping throughout the night (from 6.30pm to 7.00am) as well as napping during the day, and you have a really good appetite and aren’t afraid to try new foods. Mary has taken you to playcentre where she watched you play in the sandpit with a couple of the other children and do some fingerpainting. Mary also noticed that you really enjoyed following some of the older children around at playcentre and trying to participate in the activities they were doing. Mary will be taking you to playcentre at least twice a week for two hours at a time while you are staying with her to help you strengthen your social skills and get you used to being around lots of different people.

The biggest challenge Mary has had in looking after you so far has been hair washing. You don’t mind being bathed but every time Mary tries to wash your hair you cry and try to move away from her. Mary has talked with some of the mothers at playcentre about strategies she can use to make hair washing a more enjoyable experience for you. These include putting toys in the bath and singing to you. She is trying both of these with you and thinks that every day you are becoming more and more comfortable with having your hair washed. I have also arranged for a Plunket nurse to come and visit you and Mary next Monday morning (29 August), and Mary will ask if she has any suggestions as well.

Education, Recreation, Health

Where is the child being educated and are there any issues? Is the child attending any other activities i.e. sport, dancing etc? Are there any health issues?

  1. You are due for your 15month immunisations. Mary will make an appointment for you with your doctor before the end of this month.
  2. The eczema on your stomach, back and arms is starting to clear up and the cream Mary is applying twice daily seems to be helping a lot. Mary needs a prescription for a new pottle of cream so I will contact the pharmacy today to organise this.
  3. You and Mary will attend playcentre twice a week for two hours at a time; Mary will make the decision about which days are most appropriate dependent on both your schedules.

Contact with family

Is family contact meeting the child’s needs?

I will meet your family this week at a whānau hui on 25 August to discuss how contact with them will look, and I will keep trying to locate your mum and dad too.

Progress of the plan/goal

Is progress being made on the plan towards the goal? If not, what are some of the barriers and tasks to resolve them?

A family group conference was held for you on 17 August 2011. At this conference your family decided you weren’t being well looked after by your mum and dad and you needed to live somewhere safe until your mum and dad have learned how to be better parents. Your family has not been able to agree on who should look after you until it is safe for you to go home; that’s why you are staying with Mary in the meantime.

I’m holding a family meeting on 25 August during which I will discuss my concerns about not being able to find a family placement for you, and the need to set up contact between you and your parents and other family members.

Tasks to be completed

From my visit has there been anything identified that requires further follow up?

To help you with your development and ensure Mary has all the knowledge and support she needs to foster this I will make a referral to Footsteps for you by 26 August 2011.