Procedure - Case Noting and Case Reporting

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Purpose
1.	Responsibility
2.	Principles
2.1	Release of case notes and case reports to prisoners
3.	Case Notes
3.1	Frequency of Case Noting
3.2	Guidelines for Case Noting
4.	Behavioural Case Reporting
4.1	Frequency of Behavioural Case Reporting
4.2	Frequency of Behavioural Case Reporting for Prisoners not subject to an Offender Rehabilitation Plan, including Remand Prisoners
5.	Employment Case Reporting
5.1	Frequency of Employment Case Reporting
6.	Guidelines for Behavioural and Employment Case Reporting
7.	Intervention Case Reporting
7.1	Frequency for Intervention Case Reporting
7.2	Guidelines for Intervention and Education Case Reporting

Purpose

To record pertinent information on the Integrated Offender Management System (IOMS) about offender management, behavioural standards and attitude while in custody (remand or sentenced); compliance with conditions and participation in risk-reducing activities as relevant, which contributes to the prisoner's overall management, classification and placement.

The recording of interactions with prisoners through timely and accurate case noting is an important aspect of dynamic security and the maintenance of the security and good order of a corrective services facility, including the safety of staff and prisoners.

1. Responsibility

All staff members within a corrective services facility are responsible for case noting and case reporting including, but not limited to: education officers, psychologists, correctional counsellors, cultural counsellors, trade instructors, custodial correctional officers, custodial supervisors, sentence management staff, and activities officers.

The minimum standard for reporting as set out in this procedure must be achieved for each prisoner. The general manager of each facility must ensure case notes and case reports are completed on all prisoners whether they are remanded or sentenced (refer procedure - Admission). A schedule of case notes and case reports must be established on IOMS for each prisoner and must be consistent with the minimum standards of this procedure and with Offender Rehabilitation Plan and Individual Management Plan requirements.

The general manager must ensure that all relevant staff receive training on case noting and case reporting.

Managers and supervisors will monitor and audit the completion of case notes, and behavioural case reports in accordance with this procedure and the schedule on IOMS on a monthly basis, and record a case note identifying that an audit has been conducted. It is important that managers and/or supervisors do not give feedback within individual case notes written by staff.

2. Principles

Case notes and case reports will support the completion of quality offender management documents, which will contribute to integrated offender management. This in turn will support the safety and security of a corrective service facility; for example, prisoners will have security classifications which reflect their level of risk.

When developing case notes and case reports relating to a prisoner the following should be documented-

1. information that will assist in the management/intervention of prisoners;
2. communication relating to a prisoner's management;
3. information relating to changes in behaviour; and
4. referrals/directions given by an officer to perform any required action and follow-up needed.

Case notes and case reports should-

1. be professional, relevant, accurate, objective, clear of bias, consistent, comprehensive, accountable, and of a professional tone;
2. NOT contain any gratuitous or derogatory remarks;
3. only include common abbreviations (eg. Urinalysis Test - UT); and
4. not make reference to names other than that of the prisoner.

2.1 Release of case notes and case reports to prisoners

The general manager of a corrective services facility must establish a process that provides for prisoners to be provided a copy of case notes and case reports. A general manager may refuse release or censor information (censoring includes removing or redacting information) in a document to be released on the grounds of safety and security, including-

1. name of the author of the document;
2. name of a staff member other than the author of the document;
3. name/details of another prisoner
4. advice/recommendation/assessment of a prisoner considered to be of a sensitive nature.

An officer that has concerns with the release of information contained in a case note or case reports may contact the general manager and request that the information is not provided to the prisoner.

Refer - CSA, s 341 and procedure - Disclosure of Confidential Information.

If a general manager refuses to release a document on safety and security grounds or the prisoner is provided a censored document, the document may still be subject to release under relevant legislation (refer Right to Information Act 2009 and the Information Privacy Act 2009).

3. Case Notes

A case note is a record of information that will assist in the management/intervention of a prisoner, and is a record of any noteworthy interaction or observation.

3.1 Frequency of Case Noting

The minimum reporting requirement for case noting at each corrective services facility is one regular case note per prisoner per week. A regular case note is a weekly scheduled case note written by a custodial staff member to describe a prisoner's overall behaviour, attitude, circumstances and any changes to such.

An increased minimum case note frequency is required for-

1. prisoners subject to a Maximum Security Order (refer standard operating procedure - Maximum Security Units (in-confidence) - Prisoner Management;);
2. prisoners subject to an Individual Management Plan (refer procedures - Intensive Management Plans; Planning; Review);
3. prisoners subject to a Safety Order (refer standard operating procedure - Safety Orders);
4. youthful prisoners;
5. remand only prisoners (this would include staff checking with remand prisoners and case noting whether they have legal representation/a visit at set points during his or her remand (ie. one month, three months etc);
6. prisoners transferring between corrective service facilities and/or accommodation blocks;
7. prisoners placed in a Detention Unit (refer Corrective Services Act 2006, s. 53) (refer procedure - Detention Units);
8. prisoners who are “at risk” and are not subject to a safety order (refer procedure - At-Risk Management (Self Harm/Suicide)); and
9. prisoners subject to an order under the provisions of the Dangerous Prisoners (Sexual Offenders) Act 2003 (refer procedure - Dangerous Prisoners (Sexual Offenders) Act Orders (in-confidence)).

In addition to the minimum case note frequency as per above, event based case notes will be entered by any relevant staff member to document interactions with a prisoner or significant events eg. deterioration in behaviour, emotional states, special phone calls, Urinalysis Test results, record of counselling/meetings with professional or sentence management staff.

3.2 Guidelines for Case Noting

Reporting on prisoner behaviour-

All staff must complete case notes on IOMS as per the following standards:

1. Any relevant communication, interaction or behaviour that is observed must be recorded at the earliest opportunity after it occurs (this includes, observation/interaction with prisoners not under the staff members direct supervision).
2. If a staff member observes a change in a prisoner's behaviour whether it is negative or positive, the case note must include a description of the reason/s why the case note has been made. The case note must include the action taken by the staff member to address the issue and the outcome achieved. For example, if an prisoner is exhibiting a pattern of poor behaviour the case note should recommend a case conference by the relevant correctional supervisor to address the concerning behaviour.
3. When recording case notes each statement must be explained and validated by descriptive information. For example, if the statement was that “the prisoner demonstrated anti-social behaviour”, what specific behaviours was the prisoner involved in - was he angry, and with whom, and in what context?
4. When a prisoner is new to an accommodation unit or the facility the responsible custodial correctional officer must write adequate descriptions to indicate what normal behaviour is for that prisoner. (For example, Prisoner Bloggs is out of bed prior to morning headcount, upon unlock he/she attends work in the kitchen, then attends the Making Choices program or Vocational Educational and Training courses).
5. These behavioural descriptions will be lengthier, until a pattern of behaviour has been established. This will assist staff to determine-

a. compliance with facility regulations (refer procedure - Induction - Custodial; appendix - Prisoner Information Booklet);

b. changes in behaviours related to criminogenic needs, for example, motivation and attendance at programs/intervention;

c. changes in behaviour related to stress and other factors, for example if a prisoner had a bad phone conversation, information of this nature would be significant to record via a case note to make other staff aware that the prisoner may exhibit a change in his/her behaviour (refer procedure - At-Risk Management (Self Harm/Suicide); and

d. acquisition of work and life skills obtained whilst in custody (through-care).

Once adequate descriptions are recorded to indicate a normal behaviour pattern for a prisoner it will assist to determine and/or highlight a change in behaviour, which would initiate a certain course of action in relation to the overall management of the prisoner. For example, if the change was observed as-

1. an improvement (positive), the case note may state - (eg. prisoner Smith became more open to attending the Making Choices Program); or
2. negative (eg. prisoner Smith has engaged in threatening behaviour towards two prisoners, shaking his fists and saying he will take them out). In such instances more frequent case notes may be required (as per section 3.1).

In addition, for those prisoners subject to an order under the provisions of the Dangerous Prisoners (Sexual Offenders) Act 2003, staff must record the following-

1. whether the prisoner has exhibited any inappropriate sexual behaviour towards staff or other prisoners within the correctional facility; and
2. emergent risk factors (eg. threatening behaviour).

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4. Behavioural Case Reporting

A Behavioural Case Report is a summary of case notes to provide information relevant to the prisoner's supervision, behaviour, interaction and attitude.

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4.1 Frequency of Behavioural Case Reporting

The following frequency standards for behaviour case reports have been developed as a minimum standard to support offender management.

Behavioural case reports (Periodic - monthly) are required to be completed by all custodial correctional staff on a monthly basis (including a summary of information in previous monthly periodic case reports). Behaviour reports are to be completed by the end of each month. Additional behavioural reports are to be submitted if there is a significant change in the prisoner's behaviour during the reporting period. All behavioural case reports must be entered on IOMS.

Behaviour case reports (Summary - 12 monthly) are the same format as a periodic case report; however, these reports are a summary of all information obtained from case notes and monthly periodic case reports. Summary behaviour case reports are to be completed by custodial correctional staff at least one week prior to the scheduled review and are attached to the Offender Rehabilitation Plan. All summary case reports must be entered on IOMS.

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4.2 Frequency of Behavioural Case Reporting for Prisoners not subject to an Offender Rehabilitation Plan, including Remand Prisoners

Behavioural Case Reporting will occur for all prisoners not subject to an Offender Rehabilitation Plan, including remand prisoners as per the above standards; however are not attached to an Offender Rehabilitation Plan.

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5. Employment Case Reporting

An Employment Case Report is a summary of case notes to provide information relevant to the prisoner's supervision, behaviour, interaction and attitude whilst undertaking employment within a correctional environment.

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5.1 Frequency of Employment Case Reporting

Work area supervisors are to complete employment reports on IOMS for all prisoners employed within their area. This includes custodial officers who supervise prisoners employed within accommodation units.

At a minimum one employment report is to be completed quarterly.

Additional employment reports are to be submitted in the following situations-

1. ceasing employment;
2. change of employment; and
3. significant changes in behaviour, attendance or attention to duties (Information of this nature would also be significant to record via a case note to make other staff aware of the prisoner's change in his/her behaviour).

Employment reports are to be completed by the last week of each quarter.

A Summary Employment case report must be completed at least one week prior to the scheduled review of the Offender Rehabilitation Plan for those prisoners subject to this process.

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6. Guidelines for Behavioural and Employment Case Reporting

At a minimum, information must be provided on-

1. the prisoner's institutional conduct, employment and behaviour;
2. the prisoner's attitude towards staff and other prisoners, in detail;
3. changes that the prisoner is required to make or progress that has been made in terms of conduct, behaviour, attitude towards staff, other prisoners and work;
4. pre-release/transitional activities; and
5. the prisoner's compliance with other requirements of the Offender Rehabilitation Plan.

When completing Behavioural Case Reports on prisoners subject to an order under the provisions of the Dangerous Prisoners (Sexual Offenders) Act 2003, the following must be considered-

1. Case reports must record details about the prisoner's general conduct as well as in areas linked to criminogenic needs. For example, behaviours such as if a child sex offender removes pictures of children from magazines and keeps them in his/her cell this behaviour must be reported.
2. Case officers will need to work closely with staff who have been involved in assessing the prisoner's criminogenic needs and developing and reviewing plans to ensure that case officers have a clear understanding of the types of behaviours that should be observed and recorded.

Care must be taken to ensure that the date/s of contact with the prisoner is recorded in all documents.

The recording of information will assist in determining-

1. goals and milestones, including pre-release planning, for the next review period (to be established or confirmed from the plan);
2. the offender management group allocation;
3. the prisoner's classification;
4. the prisoner's risk of escape; and
5. the prisoner's placement.

A detailed statement and/or reasons must be included in each box selected on IOMS. Each statement must be explained and validated by descriptive information, and not a generalised cut and paste of information that is not individualised to the prisoner.

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7. Intervention Case Reporting

Intervention case reports provide an overview and rating of a prisoner's participation and attitude associated with addressing their criminogenic, non-criminogenic, planning, responsivity or throughcare needs.

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7.1 Frequency for Intervention Case Reporting

An intervention case report must be completed for all interventions/educational/vocational programs undertaken during a review period for inclusion in the Offender Rehabilitation Plan and recorded on IOMS.

Prisoners subject to an order under the provisions of the Dangerous Prisoners (Sexual Offenders) Act 2003 must have an intervention report completed on a fortnightly basis. This is to include a consolidation of information from the prisoner's educational/vocational studies and/or intervention or other programs. These reports should be brought to the attention of the general manager or assistant general manager who should ensure that the plan is being complied with and that records are being kept to a required standard.

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7.2 Guidelines for Intervention and Education Case Reporting

Intervention case reports need to record, on IOMS, the outcomes from/of individual intervention/educational/vocational programs in which the prisoner has participated. Therefore, a number of individual reports may be raised for a prisoner at the review of his/her Offender Rehabilitation Plan.

At a minimum, the information in the Education and Intervention case reports must-

1. describe the prisoner's attitude towards-
   
   
   1. course;
   2. facilitator; and
   3. other participants.
   
   
2. describe the prisoner's motivation towards-
   • attendance; and
   • completion/response to course;
   • application of skills.
3. describe the prisoner's conduct-
   
   
   1. shows respect; and
   2. adheres to rules and regulations.
   
   
4. describe the prisoner's interaction with-
   
   
   1. facilitator; and
   2. other participants.
   
   

Include any recommendations for the next review period. This may include the completion of currently enrolled interventions/programs/courses/additional courses.

For those prisoners subject to an order under the provisions of the Dangerous Prisoners (Sexual Offenders) Act 2003, staff must record the following-

1. compliance with Individual Management Plan and Offender Rehabilitation Plan; and
2. whether they have displayed a level of insight and/or preparation with regards to reintegration planning.

Endorsed by:

MARK RALLINGS

Executive Director, Offender Intervention Services

Approved by:

PETER BOTTOMLEY
Acting Commissioner

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Version History

14/11/2011 Version 03 - 10/03/2011 Version 02 - 29/10/2009 Version 01