Mandatory Case Note Taking

In alignment with best clinical practice, providing case notes is now mandatory for all EAP appointments and is captured during the completion of any EAP appointment in Phoenix.

This requirement applies to all EAP engagement types at Converge, including employee consultants, Converge partners and associates.

Providing case notes ensures that Converge can:

• Provide EAP case notes to customers upon request 

• Comply with court ordered subpoenas when served

• Conduct timely reviews when a customer is assessed to be at risk and immediate action is required 

• assess the need for extra sessions or undertake a clinical review where required 

• address and respond to feedback from a customer or client organisation as part of our ongoing quality assurance and feedback management process.

In this guide:

Providing case notes

While completing an appointment from the Quick View page of Phoenix, the “Reported issues & outcomes” page (the case note taking page) now has mandatory fields for you to complete.

Open

You can choose to either:

• upload your case note file (Word, .PDF file or image), then click Continue to move on to the next page.

• OR If you’ve typed your notes in a word processor or another platform, you can copy and paste the notes into the relevant fields into Phoenix directly.

If you are uploading case notes

Click the button and upload a Word document, .PDF file or image of the notes. Once completed, scroll down and click “Next” to proceed. You don’t need to enter the notes anywhere else on the page.

If you are typing in, or copying and pasting your notes into the text fields instead

Ignore the button and instead, enter your case notes into the relevant text fields. You will also need to indicate if a mental health risk assessment was completed. Then click Next to proceed.

Case note formatting and templates

If you prefer to upload your case notes, your notes should be clear (typed), concise and objective - we recommend you follow this guidance on the Clinical Governance Portal (CGP):

• Case Note Policy for employee consultants: Case note policy (employees)

• Case Note Policy for Converge Partners and Associates: Case note policy (partners and associates)

Use of AI tools for Case Notes

If you are thinking of using an AI tool, the following are key compliance requirements: 

Employees - approval from clinical leadership team/line manager is required 

Converge Partners and associates - any AI tool used must comply with the following: 

• Store and process data within Australia: This minimises risks associated with international data transfers and ensures compliance with local data sovereignty requirements. 

• Obtain informed patient consent: Before recording or transcribing consultations, explicit consent must be secured, with clear communication about how the data will be used and stored. Consent must be recorded in case notes 

• Data security measures: Case notes are stored securely with strict access controls to protect sensitive information. 

• Avoid unauthorised secondary data use: Data cannot be used for purposes beyond the original intent without explicit consent. 

• Ensure accuracy and human oversight: AI-generated documentation should be reviewed by consultants to confirm and ensure they meet Converge case note standards as outlined in Converge’s Case Note Policy. 

Viewing case notes after submission

If you need to view case notes you’ve submitted for previous appointments view the guide below for information:

Viewing and adding case notes (via Quick View) - External

Incorrectly uploaded case notes

Please note case notes are considered health records and as such, under the Health Records Act 2001 (Vic), the Privacy Act 1988 (Cth) and My Health Records Act 2012 (Cth), you are unable to amend or delete notes that have been submitted, even if in error.

If you have accidentally submitted the wrong case notes and have marked the appointment as completed, please follow this guide:

• For Converge employees: Incorrect case notes- Employees

• For all consultants (except employee consultants): Incorrect case notes uploaded

Need further assistance?

If you need more help or information about this change or how to follow the mandatory case note taking procedure, raise a ticket with User Support here: www.convergeinternational.com.au/consultant/eap