How to Create a Case Note Template for Your NDIS Team

A useful case note template gives staff enough structure to record support clearly while leaving room for the participant’s own experience. The starting point is the work your team does: what should the next worker, supervisor or reviewer be able to understand from this note?

This guide focuses on designing a format for a team. For help with the wording of an individual note, see how to write NDIS progress notes. If you need a standalone starting format, use our free progress notes template.

Start with one Service and a clear purpose

Choose a Service where staff regularly write the same kind of record. Ask a worker and a reviewer to describe what makes a note useful, and where they currently have to chase missing information.

For a community access Service, that might be the assistance provided, the participant’s response and any agreed follow-up. Another Service may need different prompts. Give each section a clear job so staff do not repeat the same narrative in several places.

Keep participant identity, Service, session dates and author details separate from the narrative prompts when your system already records them. Repeating these details inside every response creates extra work and opportunities for disagreement between fields.

An adaptable community access example

The following is a fictional example to adapt with your team, not an official NDIS form or a preloaded MyCaseNote template. The required settings are suggested choices for this example.

Support delivered — required

Prompt: What did the participant do, and what assistance did you provide? Describe the support rather than listing the activity alone.

Example response: Alex chose to visit the library. I supported Alex to check the bus route before leaving and prompted them once to identify the return stop.

Participant response — required

Prompt: What did you observe? Attribute comments to the person who made them and distinguish those comments from your observations.

Example response: Alex located the library entrance without prompting and asked the librarian where to find cookbooks. Alex said, “I would like to come back next week.”

Progress and barriers — optional

Prompt: Was there a relevant change or barrier? Give a specific observation and identify any earlier record used for comparison. Do not assume that every session demonstrates progress.

Example response: Alex checked the return route using the bus app. The app did not load at the stop, so we used the printed timetable together.

Follow-up — required

Prompt: Record any agreed next action and who will take it. If no follow-up was identified, say so explicitly.

Example response: At the next scheduled session, I will ask Alex whether they would like to practise using the printed timetable before travelling.

These prompts encourage concrete observations without asking staff to make an assessment beyond their role. Compare them with our good and bad progress note examples when reviewing the language your team uses.

Choose required sections carefully

Make a response required when it is meaningful for every note using that template. A required field confirms that someone entered a response; it cannot establish that the response is accurate or useful.

Before marking a section required, check:

• Can workers answer it from what they actually know?
• Will it apply to each session using this template?
• Does the prompt explain what to write when there is no relevant event or follow-up?
• Is the same information already recorded elsewhere?

Keep less common details optional or consider a separate template when the work differs substantially. Review repeated “not applicable” responses during the trial: they may indicate that a section does not belong in the default format.

Introduce the template with a small trial

1. Agree on the purpose, section labels and required responses with a worker and a reviewer.
2. Complete fictional examples for an ordinary session and one with a change of plan.
3. Check whether prompts produce useful detail without duplicating information.
4. Trial the format with a small group following your organisation’s normal documentation process.
5. Review the notes together and improve unclear prompts.
6. Nominate the default format and show the wider team when to use alternatives.

Pair the format with a case note review workflow. A template supports consistency, while review helps identify vague language, missing context or follow-up that needs attention.

Use and maintain the format in MyCaseNote

With custom case note templates, authorised managers can create ordered rich-text sections for a Service, add help text and set required responses. A Service can have several active templates and one active default; the standard form remains available.

Staff choose their format before the first save. Incomplete drafts can be saved, and required sections must be completed before submission. Once saved, the note retains its original template structure even if a manager later edits or archives that template.

Duplicate a useful template into another authorised Service when needed, then adapt the copy independently. Archive an old format when it should no longer be used for new notes.

When records need to be reviewed together, case note PDF exports include the saved template labels and responses in order. That lets the structure you designed remain understandable beyond the individual note screen.