Best practices for note-taking in organisations
What can we put in notes? It’s a question that organisations seek advice on regularly.
The challenge with notes is they are usually free text fields and can be as long as you want which is great for flexibility, however from a data protection perspective, what is written in notes would be disclosable during a Subject Access Request process and they can frequently contain opinions (not so great).
Here are some of the scenarios which can be challenging
1. Subjective Comments: Recording subjective comments in notes is a common issue and these can be problematic if disclosed but are also unnecessary for the notes process.
Example: “John is lazy and doesn’t get along with his teammates.”
Example: “Customer seemed drunk and was very rude.”
2. Speculating about health: Making personal judgements about a persons health.
Example: “Customer seemed disorientated”
Example; “Client appeared to be depressed”
3. Recording Hearsay: This includes recording hearsay or unverified allegations.
Example: “Several employees suggested that Sarah might be stealing from the company.”
Example: “It is alleged that the client lied on the form”
4. Recording Family Details: Including information about an individuals family or personal circumstances which is unnecessary for the purpose.
Example: “Tommy’s parents are going through a messy divorce, which explains his recent outbursts.”
Example: “Susan has become the carer for her elderly father and it is affecting her work”
Good Practices for Note-Taking
1. Stick to Facts: Focus on objective, verifiable information rather than subjective opinions or speculation.
Good example: “John completed 3 out of 5 assigned tasks this week.”
2. Relevance is Key: Only include information that is directly relevant to the purpose of the notes.
Good example: “Customer reported issues with product X and requested a refund.”
3. Use Professional Language: Avoid informal or emotional language, and maintain a professional tone.
Good example: “Patient reported severe abdominal pain; further tests recommended.”
4. Be Concise: Keep notes brief and to the point, avoiding unnecessary details.
Good example: “Meeting discussed Q2 budget – action items assigned to finance team.”
5. Avoid Assumptions: Don’t make or record assumptions about individuals or situations.
Good example: “Employee requested time off for personal reasons – approved for next week.”
6. Regular Review: Implement a system for regularly reviewing and updating notes, removing outdated or irrelevant information.
7. Training: Provide clear guidelines and training for staff on appropriate note-taking practices.
By following these practices, organisations can maintain useful and informative notes while minimising the risk of including inappropriate or potentially harmful content. Remember, good note-taking is about capturing essential information accurately and professionally, always with the awareness that these notes may be read by others in the future.
If you would like to discuss good note taking practices please book a call here