Documentation in Client Files & Case Narrative Training

1. Documentation in Client Files & Case Narrative Training 2010 Case Manager Training

2. Client Files • Client File • Information about clients and services • Central to professional and organizational accountability • Why keep a client file? • Client information in a single location • Easily accessible and organized • Adjust care plan

3. Client File • Included • Intake/Prioritization • Current assessment and last year’s assessment • Hand written and turnaround (CIRTS Printout) • Release of Information • Privacy Practices • Grievance Procedures • Financial Worksheets • Current care plan and last year’s care plan • Program Specific forms • Client enrolled in • Case Narratives • Notes

4. Monitoring Staff • AAANF monitors client files • Read case note (case narrative) • Needs to be legible • Understand client’ situation • All information in case note and care plan is connected to the information in CIRTS • Understand services provided • Formally- through your agency • Informally- by family/friends

5. Why is a case note important? • Billing purposes • Case notes must contain sufficient information • Day to day documentation of case management and case aid billing units • If you don’t bill units for the work you’ve done, then your agency doesn’t get paid • Non-billable activities need to be clearly noted as well • Billable services • Refer to your Program and Services Handbook from the Department of Elder Affairs

6. Purpose of Client Files • Individualize • The client • Situation • The need • Service transaction • Linking client to resources available • Goals • Plans • activities • Resources • Contains all communication and actions taken with that client

7. Initial Case Notes / Case Narrative • Included Information • How was the client referred • Summary of the assessment • Section by section • Not an essay of the assessment • Provide clarification to the 701B assessment • All planned activities to address clients’ need • Description of the client’s home situation • Environmental • Physical or emotional observations • Current gaps in services • Non-DOEA services • Friend/family members

8. Case Note /Case Narrative • Observations • Based on FACTS! • What did you see in and around the home? • What did the client or caregiver say? • How did the client appear? • Physical and emotional • Examples • “The client seemed…” • “ The client appeared…” • “ The client stated…”

9. Case Notes / Case Narrative • Significant observations of the client • Hygiene and grooming • Did the client’s hair and skin appear clean? • Physical appearance • Was the client dressed appropriately? • Face expressions / affect • Crying, moaning etc • Mannerisms • Response to others • Interaction with you or family members • Caregiver changes • No significant changes with the client or caregiver • Document if there have been no changes

10. Initial Case Note / Case Narrative • Included Information • Specific to each service • Dates that services will begin • Duration of each service • Ex. 3 bath visits per week • Professional perception • State Facts NOT opinions • Ex. Describe the odor you smell NOT that the client smelled badly

11. Initial Case Note / Case Narrative • Excellent case note • Reader should be able to • Get a concise picture of the clients’ situation • Prior to receiving services • Know what is expected by implementing services • Not have to ask the case manager questions about the situation • Documentation • Case notes • Within two weeks (14 business days) • Document to ensure that the services were delivered

12. Annual Case Notes • Completed with the annual assessment • Changes • Home / Living situation • Health • Income • Mood • Cognition • Behavior • Consider the services now being provided • How the services have improved clients’ situation • Client’s satisfaction with the services • Similar to initial case note • Section by section on the assessment

13. Interim Case Notes • Always document • When you spoke to the client • Tried to contact client • Any changes in their situation • Hospitalization • Lapse in co-payment • Death in their family • Crisis • Changes in service delivery / Care Plan • When you do something on behalf of client • Reduce services • Handle client complaints • Suspect abuse, neglect or exploitation • Call the Abuse Hotline and DOCUMENT!

14. Interim Case Notes • Interim Notes Include(but not limited to) • Date, time, setting, participants involved • Behaviors observed (if applicable) • What was revealed / spoken about • In as much factual detail as possible • Actions taken • Actions planned for future • Act like if it is not written, it never happened

15. Documentation • What not to document • Biased information or opinion • Personal frustration with the person/ situation • Derogatory remarks • Client / caregiver • Another agency • Your agency • Never write anything that makes your agency or you appear petty, uncaring, negative or incompetent

16. Remember • An effective case manager should write and prepare every client file as though it was certain to be reviewed in a courtroom • Anything you write can be seen by the client, caregiver or other provider • Use common sense • There may be additional requirements for client files based on the program • Be sure to include the required documentation • If you are unsure • DOEA Program and Services Handbook • Medicaid Waiver Handbooks • Ask someone!!

17. Questions?