Writing Notes That Stand Up: Legal Insights for Case Managers
Case notes are more than a clinical record — they are a vital part of the legal process. When a case enters litigation, your notes may be reviewed by solicitors, barristers, and even the court. The quality and accuracy of your documentation can directly influence how decisions are made, how evidence is interpreted, and how your professionalism is perceived.
Why Notes Matter
Your notes tell the story of the case. They demonstrate your clinical reasoning, decision-making, and accountability. In the legal context, they become evidence — not just for what happened, but for how and why you acted in a particular way.
But notes can also become a point of contention. Sometimes, your records will contain information that isn’t directly relevant to the legal claim — for example, personal reflections, wider wellbeing observations, or details about other services involved. When a case reaches disclosure, a significant amount of time (and cost) can be spent debating what’s admissible, what should be redacted, and whether certain information is legally privileged.
This is one of the biggest challenges in medico-legal work. If your notes blend clinical progress updates with litigation-related material, it can create ambiguity over what can or should be shared. The advice from our legal panel was clear: keep these records separate wherever possible. Maintaining distinct medico-legal and clinical progress notes helps remove confusion, protects privilege, and prevents unnecessary disputes — the kind that can easily escalate to court.
Best Practice Tips
1. Be factual and objective.
Avoid speculation, assumptions, or emotional language. Record what you saw, heard, and did — not how you felt about it.
2. Record contemporaneously.
Write your notes as soon as possible after the event or meeting. The closer to the time, the stronger their credibility.
3. Include key details.
Dates, times, attendees, actions agreed, and decisions made should all be clearly stated. These details often make the difference in legal scrutiny.
4. Link to supporting documents.
Cross-reference therapy plans, expert reports, and MDT meeting minutes where relevant. This strengthens the evidential trail.
5. Maintain consistency.
Use a standard format and tone across all entries. Consistent record keeping reflects professional practice.
6. Secure your notes.
Always store records in a secure, GDPR-compliant system. Data protection is a legal as well as ethical obligation.
Common Pitfalls
Vague or missing entries: Gaps in documentation can raise doubt or create space for dispute.
Failure to document decisions: Especially around therapy changes, funding, or safeguarding — omissions here can carry significant risk.
Inadequate handover notes: Poorly documented transitions can disrupt care and expose liability.
Bias in joint instruction cases: Notes should remain neutral and accurately reflect the views and input of both parties.
Mixing clinical and legal documentation: Combining progress notes with medico-legal material blurs the boundaries of privilege and disclosure, creating unnecessary risk.
Final Thought
Documentation is both an art and a safeguard. Good notes don’t just protect your professional integrity — they protect your clients, your colleagues, and the process itself. Clear, objective, and well-structured records save time, prevent disputes, and uphold the credibility of everyone involved in complex litigation.
At Healthy You, our focus is on helping case managers thrive in demanding roles. Through training, supervision, and peer forums, we create spaces where you can build resilience, share experiences, and strengthen practice. If you’d like to explore these themes further, or simply hear how other case managers are approaching their work, join one of our free Case Manager Confidential sessions — a confidential forum designed to offer both support and practical insight.
For details, contact sarahsawyer@healthyyoultd.co.uk