How to create or edit a Client Journal (case note)

Client Journals in SupportAbility refer to any case notes or evidence that is recorded about a Client. 

This article outlines how to create a Client Journal, the recommended fields for completion, and the optional fields available for completion when adding a Client Journal, as well as editing a Client Journal. 

Audience: Team Leaders, Support Staff, and anyone tasked with creating Client Journals.


Summary

The following list summarises the content within this article. Click on the links below to take you to the relevant sections:


How to create a Client Journal

Journals can be created from a number of places in SupportAbility, from the Journal tab of the Client's record, from any Goal records that have been created for the Client, or from within the Activities the Client participates in also. 

Adding Client Journals from the Activity record for the Activities they participate in, links the Journal evidence with service delivery and is therefore recommended.

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Adding a Client Journal from the Journal tab

To add a Client Journal from the 'Journal' tab of a Client record, select the '+ Add a new Journal record' icon: 

Select a Site/Service

The first step that is required is to add the Site and Service the Journal is related to: 

In this example, there is only one Site/Service available to select from based on Jeremy's privileges. However, the Site/Services available for selection are based on your Staff Account privileges and the status of the Client's Service Participation in these Site/Services is listed next to each for reference: 

  • Current - indicates that the Client currently participates in the Site/Service
  • Historical - indicates that the Client participated in the Site/Service historically
  • Not Used - that the Client has never participated in this Site/Service

Once selected, the 'New Journal' record is created: 

More on the recommended fields for completion has been outlined below. 

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Adding a Client Journal from the Activity record

To add a Client Journal from the Activity that the Client is participating in, select the '+' icon for the relevant Client in the Journals column: 

When a Journal is added from the Activity record, the Activity is linked to the Journal, and the Site/Service the Activity is being facilitated by is listed as the Service. The name of the Activity is prepopulated in the Activity field and is also duplicated in the Title of the Journal, however, can be updated as required: 

N.B. Multiple Journals may be added for each Client within an Activity.  Once a Journal has been created from the Activity, a number icon will be visible to indicate the number of Journals that have been created within this Activity for that Client:

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Recommended fields for completion

When a New Journal is created, the key areas to update include: choosing the relevant Client Journal Type, adding a descriptive Title for the Journal, entering Journal Notes, as well as adding any of the relevant Client Goals and/or Goal Strategies where necessary:

It is important to note that adding a Journal Action is optional unless this has been configured as being mandatory based on the Client Journal Type selected. If this is the case, you will not be able to save the Client Journal until a Journal Action has been added. Please see the Journal Actions section below for more information. 

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Client Journal Type

When a Client Journal is created, the Journal Type that your organisation has configured to display by default is pre-selected. In this case, the Journal Type of 'File Note' displays as the default Client Journal Type as this is what has been configured:

However, it is recommended to choose the most appropriate Journal Type from the options available in the drop-down list e.g. Program of Support | Outcome Progress

N.B. A default list of Journal Types is included in every SupportAbility installation, these can be configured by your organisation as outlined in the Configuring Journals article linked below, therefore, the available options to select from are based on the Journal Types your organisation has configured. 

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Journal Templates

Specific Journal Templates can be configured for each Journal Type as required, to prompt Staff to record key information. The corresponding Journal Template is populated in the Notes field when the relevant Client Journal Type is selected:

The relevant Notes can be entered in relation to the template. 

Please see the  Configuring Journals article linked below for more information regarding configuring Journals.

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Title

When the Journal is first created, 'New Journal' will display as the 'Title' by default when the Journal is created from the Journal tab: 

Or with the same name as the Activity when created from the Activity record: 

It is recommended to enter the most applicable 'Title' for the Journal evidence e.g.  Week 1 | Social POS which updates the name of the Journal also: 

It is important to add a descriptive Title to the Journal to help you identify it in future. Some providers also request their Staff Members to add their initials as part of the Title:

As this helps to identify who has written which Journal, when Journals are being added from the Activity record: 

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Notes

The 'Notes' field is where the actual case note information or Journal evidence is recorded: 

N.B. The 'Notes' field expands as required so as much information can be recorded as necessary here.

If a 'Journal Template' has been configured by your organisation for the 'Client Journal Type' selected, this will display in the 'Notes' section and the relevant Notes can be entered around this: 

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Goals

Goals and Goal Strategies can be added to the Journal evidence to help track the Client's Goal Progress:

N.B. Adding or editing Goals and/or Goal Strategies is only possible before the Journal entry has been locked. 

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How to Add a Goal/Goal Strategy

To add a Goal and/or a Goal Strategy, select '+Add Goal': 

Step 1: Goal

This opens the 'Add a Goal to Client Journal' window for the relevant Goal to be selected first. Each of the active Client Goals is displayed in the 'Goal' column and a numeric value indicating the number of Goal Strategies associated with each Goal is displayed in the 'Goal Strategies' column. 

Select the relevant Goal first by clicking on the 'Select' button: 

The selected Goal will be displayed:

If there are Goal Strategies associated with this Goal, you will be prompted to select a Goal Strategy option next. 

Step 2: Goal Strategy

The selected Goal is displayed and the associated Goal Strategies are listed for selection where required:

If you do not wish to add a Goal Strategy and just the Goal itself, you can select the option of 'Goal Strategy not required'. If there are no Goal Strategies associated with the Goal, you will be prompted to Save this selection instead. 

Once the relevant Goal Strategy option has been selected, select 'Save' to add this to the Client Journal record:

The Goal and/or Goal Strategy added is displayed with a link to the associated Goal record, along with any Standards which have been added to the Goal: 

If Standards have been added to the Goal, a button will appear in this column as above. Selecting this button will display a summary: 

Selecting this again will show the detail: 

Additional Standards, specific to the Journal itself, can be added in the 'Standards' section of the Journal. This has been outlined further below. 

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Goal Progress Assessment and Notes

A Goal Progress Assessment score can be recorded against any added Goal or Goal Strategies by selecting the '+' Assessment Score icon: 

To check the Evaluation Criteria, select the icon to the right of the '+' with the three lines:  

N.B. The Goal Progress Assessment Evaluation Criteria is customised by your organisation in System Preferences, please see the Configuring Goals article linked below for more information. 

Once an Assessment Score has been added, it will appear as follows: 

N.B. Assessment Score colours are as follows: 

  • 1 - 3 amber
  • 4 - 7 blue
  • 8 - 10 green

If this needed to be changed, the Assessment Score can again be selected, and updated as required provided the Journal is not yet locked. This may also be cleared if necessary: 

It is recommended to add any related Notes specific to the Client's Goal progress:

It is important to enter these notes here as these notes are what populates in the related Goal reports: 

Delete

The Client Goal or Goal Strategy may be deleted if required by selecting the contextual menu to the right-hand side of the goal i.e. the icon with the three dots: 

You will be asked once if you wish to confirm this selection: 

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Optional fields for completion

Other optional features include the ability to apply additional privacy barriers of either ' Managers Only' or 'Team Leaders Only' where necessary, adding any applicable Tags to the Client Journal, link any related Client Documents that have been uploaded to the Client record already, the option to add a Client Assessment if required, as well as any follow-up Actions to appear on the Dashboard as a reminder for completion: 


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Additional privacy barriers

The additional privacy layers of restricting Client Journal entries for 'Managers Only' or 'Team Leaders Only' is available for selection when entering sensitive information that may require further restriction:

N.B. Once this is selected, if the author does not have either of these Staff Account privileges, they will no longer be able to see this record, once saved. 

There are additional inbuilt privacy barriers for Journals that have been assigned to specialised Services such as NDIS Financial Plan Management or Support Coordination. More on this can be found in the  Journal Permissions article linked below. 

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Tags

Any applicable Tags can be added to the Journal record by selecting the '+' icon: 

Choose the relevant Tag e.g. Goal Assessment complete and then select 'Add Tag': 

N.B. Tags will only be available for selection if Journal Tags have been configured by your organisation. Please see the Configuring Tags article for more information linked below for reference

This has been added to the Journal record: 

Adding Tags is useful as the Journal Search can be used to search for Journals that have this Tag: 

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Client Documents

Up to three Documents that have been uploaded to the Client's Documents tab may be linked to a Client Journal for reference:

Selecting the down arrow in the 'Client Document 1/2/3' fields will display a list of Documents that have already been uploaded to the Documents tab of the related Client record:

Once the relevant option and 'Save Journal' button has been selected, it will display the Document name and buttons for either downloading or viewing this Document:

Information regarding uploading Client Documents to the Document tab of a Client record is outlined in the  Uploading Documents article, linked below for reference.

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Standards

There are several in-built Standards available in SupportAbility, including: 

  • Each of the NDIS Practice Standards,
  • the National Disability Standards, and the
  • DMI Codes (Disability Maintenance Instrument), specific to providers of Supported Employment. 

However, it is important to note that your organisation can customise this area of SupportAbility, therefore, what is available here is dependent on how this has been configured. 

To add a Standard to a Journal, simply select the +Add Standard button in the 'Standards' section of the Journal, which will open the Search function:

For example, to search for a Standard from the NDIS Practice Standards, (which are prefaced with 'QSF' in SupportAbility), you can either type 'Q' in the search field to access the full list of these Standards, or more specifically type a keyword e.g. 'Core' to narrow your search:

Once a Standard has been added, it will appear in the Standards section of the Journal record:

Further information regarding Standards in SupportAbility can be found in the  Standards in SupportAbility and the Adding a Standard Knowledge Base articles linked below for reference.

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Journal Actions

A Journal Action is effectively a task that requires action and can be assigned to a specific Staff member for follow-up. 

Journal Actions can be created within a Journal entry e.g. 

Notifications for Journal Actions appear on the Dashboard provided this Dashboard portal has been configured: 

Where this has been created for another Staff Member, this will populate on both the assigned Staff Member's Dashboard and the Dashboard of the Staff Member who created the Journal action so that the author can monitor its progress. However, it's important to ensure that the person a Journal Action has been assigned to can access the Client Journal before assigning them, as they will not be able to access the Journal otherwise. 

It can then be marked as Completed in the Journal e.g. 

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Editing a Client Journal 

Once the Journal has been created, only the Author e.g. Jeremy, or a Staff Member with the Team Leader privileges for the Site and Service the Journal has been created for, will be able to edit the Journal record before it is locked: 

When one of the other Staff Members facilitating this Activity, Petra views this Journal that Jeremy added, it appears as 'read only': 

This will also appear as 'read only' when the Journal entry has been locked based on how your organisation has configured this setting. By default, a Journal is set to lock five days following its creation. Please see the Configuring Journals article for more information regarding this. 

It is important to note that the Journal Date and the creation date of the record may be different so you may wish to check the information icon for more information regarding when the record was created vs. the Journal Date as required. 

The only Staff Members who can edit a locked Journal are those with the 'Edit Locked Journals' privilege. However, it is important to note that many organisations do not have any Staff Members with this privilege. Please see the 'Delete Records' and 'Edit Locked Journals' Staff Account privileges article linked below for more information regarding this. 

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