What Should Be Included in an Event Note?

What Should be Included in an Event Note?

Date of Contact
Type of Contact
Observation(s)
Action(s) towards meeting needs and desires of individual.
Follow-Up
Facts and verified information
Objective statements
Relevant Information

Title of the Event Note

Suppose there is an emergency or crisis after hours, on the weekend, or during a vacation. In that case, other people not as familiar with the case will review the notes and look for relevant and pertinent information to help the individual. Therefore, the note’s Title should clearly indicate what is being documented within the note.
A poorly titled note can result in valuable information being overlooked or take up time during an emergency.

Observation(s)

Issues regarding the individual’s quality of life, satisfaction with services, current life situations, and all health and safety issues.
Personal opinions, judgments, or subjective perceptions must not be included in the case note.

Action(s)

Document actions that have taken place during the contact.
What happened as a result of the contact with the individual/provider/family member, etc.
Actions should have a clear link to the plan of care or document progress towards meeting needs and desires of individuals.

Follow-Up

The follow-up includes the actions which need to take place.
What needs to happen and who will do it.

Facts

Notes should include facts and verified information. Do not write assumptions, opinions, or rumors.
Notes should be objective, not subjective.

Subjective can mean the information is influenced by the authors feelings.

Objective means the author sticks to the facts, without adding extra details based on their own feelings.

Emails

Do not copy and paste emails to your incident report narratives. Attach the email as a file. The email information can be summarized.
You CAN copy and paste the entire email, including names and date stamps into events.

Acronyms and Abbreviations

Acronyms and abbreviations are acceptable as long as they are defined before they are used in each note.

Illustration of a woman with blonde hair in a bun wearing a read jack and black glasses

Ronnie says, “Remember, these event notes are a legal document, subject to open records. Here are a handful of tips to assist you in writing a good event note.”

Clear, purposeful, and links to the plan of meeting the individual’s needs and desires.
Free of grammatical and spelling errors.
Must be factual and observable.
Only includes commonly used acronyms or abbreviations.
Makes sense to any neutral party.
Assumes that the reader is not familiar with the case.
Covers a specific event and does not summarize long periods of time.
Events are able to be edited in KYGFIS by the author for up to 24 hours.