Case notes vary from hospital to hospital so be sure to check for any policies and procedures to insure you are in compliance.
This handout is a roadmap for what should be included in case notes during a patient in-take.
You'll notice two icons - a pencil and a pill bottle. The pencil indicates a tip to better understand how to process a particular area. The pill bottle is just as it should be as an emblem, indicating something drug related is noted.