Case notes

Where the case notes are

Every room and every case has a “Case notes” card. If there are already entries, it is called “History and case notes”. New entries are at the top, and you expand older ones. Clicking an entry shows the full text. You find all your cases together in “My workspace” at the top under “Case notes”.

Writing an entry

1. Click “New entry”.
2. Check “Date”, “Time”, “Duration in min.” and “Type”. An entry cannot be in the future.
3. Under “Key points”, write briefly what happened. Please without names, addresses or phone numbers.
4. Choose how the text is created: “Draft from key points”, “Write it yourself” or, if your centre allows it, “Create AI draft”.
5. Check the text, make the risk assessment and click “Accept”.

The entry is only saved with “Accept”. “Discard” deletes the draft. onlineberatung.digital does not store the key points themselves, only the text you accept.

Sections and summary

Without its own template, an entry has a single text field. Your centre can have a template with several sections. The platform operator sets this up for your centre. Then words such as “Strengths:”, “Agreement:” or “Next step:” in your key points start a section. Everything after them goes there until the next such word.

The “Summary for the history” is one line for the overview. If you leave it empty, the first sentence is shown there.

The AI draft

If your centre allows the AI draft, you see the “Create AI draft” button. The AI writes a text from your key points. It is a suggestion that you check and adapt.

Before that, onlineberatung.digital removes the pseudonym, your note, the names of the people involved, contact details, addresses and sequences of numbers. Anything that cannot be reliably detected stays in. That is why names do not belong in the key points. Where the key points go for the draft is shown directly below the buttons. Each draft is created only from the key points of this one entry. Entries with an AI draft are marked “with AI draft”.

The risk assessment

Under “Risk assessment · made by you, not the AI” you tick whether there are “Signs of self-harm” or “Signs of a risk to child welfare”. If certain words appear in your text, onlineberatung.digital asks you to check the assessment carefully. You always do the ticking yourself. The history then shows “Self-harm ticked” or “Child welfare ticked”.

Who can read the case notes

The case notes are stored encrypted. Only you and a co-counsellor, if one has been added, can read them. The client, the office and the lead of your centre never see them. The platform operator does not see any content in the administration either.

You add a co-counsellor in the “Case and people involved” card under “Co-counsellor”, for example for couples counselling with two counsellors. You can choose from the active counsellors at your centre. Only the responsible counsellor can add one. Each entry shows who wrote or changed it. In an online room, the co-counsellor also reads the messages. That is why their name then appears in the client's room.

If you change centres, the centre lead hands your rooms over to a colleague. They then also see the case notes.

Changing and deleting

“Edit” changes an entry. Each change becomes a new version. You find the older ones under “Earlier versions”. You cannot delete a single entry. The case notes are deleted with the room once your centre's retention period has expired after closing. More on this in Rooms and messages.