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

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

This article outlines how to create and edit a Client Journal, including the required fields for completion and differences when adding a Client Journal from an Activity record.

The available optional information that can be added to a Client Journal is also covered in detail including linking the Journal to the relevant Client Goal Strategies and/or Client Goals to demonstrate progress toward these, creating Journal Actions (tasks) for follow-up and linking any relevant Standards.

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


Summary

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


Where can Client Journals be created from?

Journals can be created from a number of places in SupportAbility by selecting the + icon to 'Add a new journal record' as follows:

  • the 'Journal' tab of a Client record:

    N.B. The Journals displayed here are filtered based on the Staff Account privileges and Service access a Staff Member has, as per the Warning Notification at the top. 

  • the 'Goal Details' section of the Client Goal record:

  • the 'Journals' section of the Goal Strategy record (within the Client Goal record):

  • the 'Clients' section of an Activity record:

The steps involved in creating a Client Journal are outlined in detail below, however, it is important to note that when creating a Journal from an Activity there are some additional considerations which are covered in the following section.

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Adding a Client Journal from an Activity record

Adding Client Journals from an Activity record for the Activities they participate in is recommended as this links the Journal evidence directly with service delivery.

Multiple Journals may be added for each Client within an Activity by selecting the '+' icon under the Journals column.  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.

Selecting the number icon will display the Date and Title for each Journal record which when selected will open that Journal record in a separate tab:

Some providers also request their Staff Members to add their initials as part of the Title when Journals are being added from an Activity record.  This helps to identify who has written which Journal when multiple Journals have been created for a Client.

When selecting the 'Add' Journal button in an Activity record, you will be navigated directly to the new Journal record once the Add Journal '+' button has been selected: 

The following information is automatically prepopulated in the Journal from the Activity record:

  • Activity - a link to the Activity is included here when Journals are added from the Activity record
  • Service - uses the Activity 'Service'
  • Journal Date - uses the Activity 'From Date'
  • Title - uses the Activity Description by default, however, this can be updated as needed
  • Journal Type - uses the 'Default Journal Type' when configured for Activity records

Journal Notes and any additional information can then be added.  

It is important to note that if your organisation has not configured a 'Default Journal Type' for Journals created from an Activity record, the 'Add Client Journal' window will open by default as outlined below. 

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How to create a Client Journal

When the '+' Add Journal icon is selected from one of the possible locations to add a Journal, as listed in  Where can Client Journals be created from section above, the 'Add Client Journal' window will open:

The following foundational information is required to be added here in order to create a Journal record:

  • Site/Service 
  • Date
  • Title 
  • Journal Type

Whilst Journal Notes can be entered here, they are not required to be added in this step and can be entered/completed from the Journal record once Add has been selected.

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Site/Service

Selecting the relevant Site/Service is a required field when creating Journals and the Site/Service options listed are based on the Staff Account privileges and Service/s the Staff Member creating the Journal has access to.

Staff with high-level global privileges e.g. Team Leader for ALL Services, will see all Site/Services listed and a scroll bar has been provided in these instances to assist with navigating the list:

N.B. When creating a Journal from an Activity record, the Site/Service will automatically populate based on the Site/Service configured for the Activity.

Client Service Participation Status

The status of the Client's Service Participation in each of the listed Site/Services is noted 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

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Date

By default,  when creating a Journal from the Journals tab of a Client record or within a Goal record, the current date will automatically populate in the 'Date' field:

When creating a Journal from an Activity record, however, the Journal date will automatically pre-populate to match the 'From Date' of the Activity the Journal is being created from.

If the Journal Date needs amending, select the calendar icon to update this field to the relevant date:

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Title

The Title is a required field when creating Journals. 

Entering a descriptive Title to a Journal is recommended e.g. Service Agreement Review to effectively reflect the Journal Notes and help distinguish Journals when multiple Journals have been added for a Client in an Activity: 

N.B. When creating a Journal from an Activity, the Title will automatically populate using the Activity name.  This may be amended as required.

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Journal Type

Journal Type is also a required field when creating Journals. When a 'Default Journal Type' has been configured in System Preferences for the record type where the Journal is being added, the Journal Type will automatically prepopulate here.

When no 'Default Journal Type' has been configured in System Preferences for the record type where the Journal is being added, the most appropriate Journal Type must be selected from the options available in the drop-down list:

A default list of Journal Types is included in every SupportAbility installation, however, these can be configured by your organisation as required, to ensure the available options are the most relevant for your organisation. More information is outlined in the  Configuring Journals article linked below, for reference.

When a Journal Template has been configured for specific Journal Types, this template will appear in the Notes field once selected. More on this has been outlined below. 

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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 to facilitate as much information as necessary to be recorded here.

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Journal Templates

Journal Templates can be configured for specific Journal Types when required to prompt Staff to record key information. 

If a Journal Template has been configured for the Journal Type selected here e.g. Goal Evidence, the corresponding Template will automatically populate in the 'Notes' field:

The relevant Notes can then be entered in relation to the Template. 

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

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Adding the Journal

Once all of the required fields have been completed and Notes added, select the '+ Add' button to create the Journal:

Selecting this button effectively creates the Journal record and navigates you to the Journal record, where additional information may be added as required.

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Additional Journal Details information

Once the Journal record has been created, Staff may add or update Journal Notes and additional information or attributes such as:

  • Journal Details
    • Apply additional Privacy Barriers i.e. Managers Only or Team Leaders Only 
    • Add any applicable Tags which will assist with identifying similar Journals when generating a Journal Search 
    • Enter information in the Journal Activity field if required
    • Link to related Documents which have been uploaded to the Client's Documents tab
    • Add a Client Assessment 
    • Add a Client Incident 

Information on how to complete each of these fields has been outlined below in detail. 


Unsaved Changes alerts

It is important to note that if you navigate away from a Journal when changes have been made but not saved, an 'Unsaved Changes' alert window will display:

Selecting 'Cancel' will take you back to the Journal record where the updates can be saved by selecting the 'Save Journal' button. Once saved, you can then navigate away from the Journal record as required.

Selecting 'Discard changes and continue' will navigate to the selected location without saving any of the recent changes which have been made.

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Applying additional Privacy Barriers

Additional privacy barriers are available to restrict access to the Journal to 'Managers Only' or 'Team Leaders Only':

This may be useful when sensitive information that may require further restriction is recorded. 

Once either of these settings has been selected, if the Author does not have the relevant Staff Account privilege, they will no longer be able to view this record and a notification will display 'You do not have sufficient privileges to view this page': 

Privacy Barriers for Specialised Services

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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Adding and deleting Tags

Multiple applicable Tags can be added to Journal records to assist with identifying Journals with similar attributes in a Journal Search.

To add a Tag select the '+ Add' button:

The 'Add new Tag' window will open. 

Choose the relevant Tag e.g. Support Needs from the list of available options, then select the '+ Add' button:

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

The Tag has now been added to the Journal record as shown below: 

Deleting a Tag

To delete a Tag from a Journal, simply select the cross on the applicable Tag.

The 'Delete Tag' window will open asking Staff to confirm if they are sure they want to delete the Tag as this change cannot be undone. Selecting the 'Delete' button confirms the intention to proceed and deletes the Tag from the Journal record:

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Adding information in the Journal Activity field

'Journal Activity' is a free-text field where information may be recorded for various purposes as required by your organisation:

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Linking Client Documents

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

Selecting the down arrow in one of the 'Client Document' fields will display a list of available Documents to link to the Journal:

Once the relevant option has been selected, e.g. Medical Support Plan, the Document Name and Document Date will display along with buttons to either download or view the Document file:

Remember to select the 'Save Journal' button to save the link/s to the selected Client Document/s.

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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Adding a Client Assessment

Client Assessments may be conducted periodically to track a Client's progress or decline with specific abilities e.g. Mobility or skills e.g. Independent Daily Living.  Assessment scores are assigned for each element being assessed based on pre-determined Assessment Score Criteria.

To create an Assessment record and link it to this Journal, select the '+ Add Client Assessment' button:

This will open the 'Add Client Assessment' window:

Select one of the Assessment templates from the list of available options in the drop-down menu, which have been created on the Assessments tab in System Preferences:  

Once an Assessment has been chosen, select the '+ Add' button to open the Assessment record for completion:

Select the relevant Assessment Type e.g. Ad-hoc Assessment:

Complete the Client Assessment by selecting the relevant Scores and adding Section Notes:

N.B. You will note that the Assessment Criteria are outlined on the right of the Assessment to assist with choosing an appropriate Score for each section.

Once all sections have been completed select 'Save Client Assessment' at the top or bottom of the record:

Once saved, the Assessment record has been created and linked to the Journal record it was created from.

To navigate back to the Journal record, simply select the Journal link in the Assessment record:

A link to this Assessment record will now be available in the Journal record:

All Client Assessment records including those created from a Journal, are stored on and can be accessed via the Assessments tab of a Client record:

Removing the Link to a Client Assessment in a Journal record

It is not possible to remove a link to a Client Assessment in the Journal record. 

The only way to do this is to delete the relevant Assessment record on the Assessments tab. Consideration, therefore, is needed as to whether the Assessment record should be retained or can be deleted. A new replacement Assessment could be created from this tab if required.

Only Staff with the 'Delete Records' Staff Account privilege are able to delete records including Client Assessments. 

For more information about Assessments, please refer to the  Creating Assessment Templates article, linked below for reference.

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Adding a Client Incident

Client Incident records relate to behavioural incidents. Information may be recorded about the incident including the precursor, what happened, response and outcome, along with linking the relevant Client Documents and Standards, and adding Incident Actions i.e. tasks for follow-up as required.

To create a Client Incident record and link it to the Journal, select the '+ Add Client Incident' button:

This will open the 'Edit Client Incident' view of the newly created Incident record, with the Service, Author and linked Journal pre-populated:

Complete all of the required information, then select the 'Save Client Incident' button to save the record.

Once saved, to navigate back to the Journal record, simply select the Journal link in the Incident record:

A link to this Incident record will now be available in the Journal record:

All Client Incident records including those created from a Journal, are stored and can be accessed via the 'Incidents List' section at the bottom of the Journal tab in a Client record:

For more information about Client Incidents, please refer to the  Client Incidents & Client Incident Report article, linked below for reference.

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Linking a Client Goal/Goal Strategy to a Client Journal

Where appropriate, it is recommended that Goals and/or Goal Strategies are linked to the Journal evidence to help track the Client's Goal progress. 

If Standards have been added to a Goal these will be displayed, and Goal Progress Assessment Scores and Notes can be added to linked Goal Strategies and/or Client Goals to track progress:

To link a Goal and/or a Goal Strategy to a Journal record, navigate to the Goals section of the Journal and select the 'Link Goals / Strategies' button: 

This opens the 'Link Client Goals and Strategies to Journal' window. 

The Client Goals are displayed in bold with a grey background, and the related Goal Strategies are nested below.

Where Goal Strategies are in use, it is recommended to link Journal evidence to the relevant Strategy by selecting the corresponding checkbox. For example, the following Goal Strategy has been selected for Tim:

If you wish to link Journal evidence to a Client Goal record select the 'Link Client Goal' checkbox nested below the relevant Client Goal:

It is possible to select both a Client Goal and one or more of its related Goal Strategies where required:

Once all of the relevant Goals and/or Goal Strategies have been checked, select the 'Link' button to link these to the Journal.

Separate Links will display for each of the selected items. For example, we can see here that both the Goal and one of its related Goal Strategies were selected, hence there is a separate link to each of these items and an Assessment Score and Notes may be added for each:

If a Goal Strategy and not the related Goal was selected, a link will only be available for the Goal Strategy. The parent Goal will be listed for reference only, and will not contain a link, nor will it be possible to add an Assessment Score and Notes for the Goal:

Information regarding Viewing Goal Standards and Adding Goal Progress Assessment Scores and Notes is outlined in detail below.

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Viewing Goal Standards

If Standards have been added to the Goal record, a button will appear in this column noting the number of Standards that have been linked to the Goal. 

Selecting this button will display a summary list of the Standards: 

Selecting one of the Standards in the list will display the details for that Standard: 

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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Adding Goal Progress Assessment Scores and Notes

Goal Progress Assessment Scores and Notes can be added to linked Goal Strategies and/or Client Goals to track progress.

Where a Goal Strategy has been linked and not the parent Goal the associated Goal is displayed for reference, without a link to the record, or the ability to record an Assessment Score or add any additional Notes.

To add a Goal Progress Assessment Score select the '+' Assessment Score button then select a Score from the available options: 

To check the Evaluation Criteria, select the icon with 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 the Assessment Score needs to be changed, select the value displayed to open the Assessment Score window, then either select an alternative Score or the 'Clear' button to remove the Score entirely:

It is recommended related Notes specific to the Client's Goal progress are added to explain the Assessment Score given:

It is helpful to enter Notes here as they populate in the Client Goal Report (available from the Print menu in the Client record) when the 'Show Journal Evidence' and 'Show Journal Detail' filters are activated:

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How to remove a Linked Client Goal or Goal Strategy from a Journal

The Client Goal or Goal Strategy may be unlinked from the Journal if required by selecting the contextual menu to the right of the linked Goal or Goal Strategy then select 'Remove Link': 

You will be asked if you wish to confirm this selection, as removing the linked Goal or Strategy will also discard any Assessment Score and its added Notes. This cannot be undone: 

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Adding and completing Journal Actions

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

Actions are an optional feature of Journals, however, multiple Actions may be added to a Journal record as required.

To add a Journal Action, select the '+ Add Action' button in the Actions section of the Journal record:

Once 'Add Action' has been selected, the following fields will display for completion:
  • Date Due
  • Action
  • Staff Member
  • Status
  • Completion
  • Completed By


Date Due

Select the relevant Due Date using the calendar icon:


Action

Enter the required Action details:

N.B.  While it will be necessary to scroll to view all of the Action detail entered here, the full Action details will display in the Dashboard Notification.


Staff Member

The Journal Author will display in the 'Staff Member' field by default. 

Select the down arrow to display a full list of Staff Members. Select the relevant Staff Member from the list to who you wish to assign the Action:

To assist with navigating a potentially long list of names, part of the name may be entered at the top of the List which will reduce the list to only display those options that contain the text entered:

It is important to ensure that the person a Journal Action is being assigned to can access the Client Journal before assigning an Action to them, otherwise, they will not be able to access the Journal, nor view the task in the 'Incomplete Client Journal Actions' notification portal on their Dashboard. Hence, they may not be aware it has been assigned to them.


Status

When a Journal Action is first added, the Status will display the amber 'Pending' badge by default:

The Status will automatically update when the 'Mark Complete' button is selected. More information on this is outlined below.

Once all of the Action details have been completed select the 'Save Journal' button to save the Action.


Dashboard Notifications for Incomplete Client Journal Actions

Once an Action has been saved, a corresponding Notification will appear in the 'Incomplete Client Journal Actions' section on the Dashboard of the person the Action has been assigned to, and the Dashboard of the Journal Author so the Author can monitor its progress:  

These will display provided the 'Incomplete Client Journal Actions' portal has been configured to display on the Dashboard. 


Marking the Journal Action Complete

Once the Journal Action task has been completed, the 'Mark Complete' button may be selected by either the Journal Author or the Staff Member the Action was assigned to, assuming they have access to the Journal record, and the Journal has not yet locked:

Once the 'Mark Complete' button is selected the following three fields are updated:

  • Status - the Status displays the green 'Complete' badge
  • Completion - the 'Mark Complete' button is replaced by the 'Mark Incomplete' button which allows this action to be reversed where required
  • Completed By -  the name of the person who selected the 'Mark Complete' button and the date it was selected now display in this column

Remember to select 'Save Journal' to save your updates.


Contextual Menu - 'Duplicate' or 'Delete' a Journal Action

Selecting the contextual menu (3 dots to the far right of the Journal Action) displays two functionality options, where you can either 'Duplicate' or 'Delete' an Action:

Remember to select 'Save Journal' to save your updates.


Prompt to create Journal Action

Occasionally an organisation may choose to add a 'Prompt to create Journal Action' for specific Journal Types where relevant.  When this Prompt has been configured in System Preferences and one of these Journal Types has been selected for a Journal, a blue notification message will display in two places in the Journal record as a reminder.

In the 'Journal Details' section:

And in the 'Actions' sections:

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Linking Standards to a Journal

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 to link to a Journal record is dependent on how this has been configured in System Preferences. 

One or more Standards may be linked to a Journal record.

To link a Standard to a Journal, simply select the 'Link Standards' button in the 'Standards' section of the Journal:

This will open the Search function. 

For example, to search for the following Standard, QSF: Core > 1 - Rights and Responsibilities, 9 - Independence and informed choice, simply enter one of the following, a keyword (e.g. Core), part of the Standard's name (e.g. Independence), the relevant number (e.g 9), or Standard type (e.g QSF) to display the corresponding options which match the information entered:  

N.B. The NDIS Practice Standards are prefaced with 'QSF' in SupportAbility, representing the NDIS Quality and Safeguarding Framework.

Once the required Standard has been located, select the corresponding 'Link' button.

This Standard will now be linked to the Journal record and will display as shown below:

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Notes

Notes may be added to clarify the choice of Standard which has been linked.

Remember to select 'Save Journal' to save the linked Standard.


Contextual Menu - 'View Standard' and 'Remove Link'

Selecting the contextual menu (3 dots to the far right of the Linked Standard) displays two functionality options, where you can either 'View Standard' details, or 'Remove Link' to the Standard:

Remember to select 'Save Journal' to save your updates.

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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Editing a Client Journal

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

When another Staff Member with access to a Journal views it, the only fields which will display as editable are the 'Tags' and 'Actions' functionality:

Additionally , if no Client Assessment or Client Incident has been added to the Journal, other Staff Members with access to the Journal will still be able to add one.

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Editing Locked Journals

By default, a Journal is set to lock five days following its creation, as configured on the Journals tab in System Preferences:

Please see the  Configuring Journals article for more information regarding this configuration, linked below for reference.

Once this timeframe has passed the Journal will display a blue notification message at the top i.e. 'Journal is locked - only Tags, Actions, a Client Assessment or a Client Incident can be added':

Once locked, only Tags, Actions, a Client Assessment or a Client Incident can be added to the Journal record. If a Client Assessment or Client Incident have already been added to the Journal it will not be possible to add another:


'Edit Locked Journals' Privilege

Only Staff with the 'Edit Locked Journals' privilege are able to edit all fields, other than the Client, Activity, and Author, in a locked Journal. 

It is important to note, however, that many organisations do not grant any Staff Members this privilege due to the potentially far-reaching implications of editing Journals.

Please see the 'Delete Records' and 'Edit Locked Journals' Staff Account privileges article linked below for more information regarding this. 


Journal Date and Created Date

It is important to note that the Journal Date displayed in the Journal record may in fact be different and later than the Created Date.  Therefore, a Journal may have locked within the configured time-frame but this may not be evident from the Journal Date.  You may therefore wish to check the information icon at the top for more information regarding when the record was Created vs. the Journal Date as required:

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