SPECIAL TOPICS MODULE

1. SPECIAL TOPICS MODULE CASE MANAGEMENT: CASE NOTES

2. OBJECTIVES The objectives of this module are to: Explain the function of case notes, Special Topic Module: Case Notes Demonstrate the usage of case notes, and Present guidelines for writing effective case notes.

3. INTRODUCTION A unique service provided by the DVOP/LVER Program is effective case management. As one of the most important aspects of your job, it requires consistent, accurate and complete documentation. That is why good case notes are so important. Special Topic Module: Case Notes

4. INTRODUCTIONcont… Required case documentation can vary from state to state, but the case notes you take are a continuous record of your interaction with the client. As such, they are an indispensable tool that no DVOP or LVER should do without. Special Topic Module: Case Notes

5. I. Functions of Case Notes 1. Documentation of Services 2. Clarification and Planning Special Topic Module: Case Notes 3. Tracking Progress 4. IDP Adjustment 5. Job Accountability

6. I. Functions of Case Notes: 1. Documentation of Service Case notes provide a step-by-step outline in case… • You leave and someone takes over the case, Special Topic Module: Case Notes • Your supervisor needs access to the information, or • Your records are subpoenaed by the court system.

7. I. Functions of Case Notes: 2. Clarification and Planning • By encouraging you to put your observations about the client into concise words, the note taking process helps you clarify what needs to be accomplished by both you and your client. Special Topic Module: Case Notes

8. I. Functions of Case Notes: 3. Tracking Progress • By tracking the progress of your client with case notes, you will be better equip to recognize behavior patterns or analyze employment barriers the client needs to overcome to be successful. Special Topic Module: Case Notes

9. I. Functions of Case Notes: 4. IDP Adjustment • In addition to tracking your client’s progress, case notes help you become more familiar with your client’s needs, pace and attitudes. This, in turn, will indicate if adjustments need to be made to the client’s Individual Development Plan (IDP). Special Topic Module: Case Notes

10. I. Functions of Case Notes: 5. Job Accountability • Case notes are the most accurate, complete and personalized record of your work with the client, and Special Topic Module: Case Notes • A record of your client’s progress and willingness to work towards employment and/or rehabilitation.

11. II. Using Case Notes 1. Informing your client 2. Confidentiality Special Topic Module: Case Notes 3. Accuracy 4. Brevity and bShorthand

12. II. Using Case Notes: 1. Informing Your Client • It is important to inform your client why you are taking notes and how they will be used. Special Topic Module: Case Notes • Remember, the key to effective case management is to establish a partnership with the client. You do not want to appear to be keeping secrets.

13. II. Using Case Notes: 1. Informing Your Client cont… • Share your notes with the client. • Your client should feel comfortable enough to share personal information with you. Special Topic Module: Case Notes • Sharing instills a sense of control to the client that is vital to his or her progress and independence. • Working with the client helps you keep your notes honest and accurate.

14. II. Using Case Notes: 2. Confidentiality • Do not promise that your notes will be seen only by yourself and your client. Special Topic Module: Case Notes • However, you should make every effort to keep the information secured in a confidential file and under lock and key.

15. II. Using Case Notes: 3. Accuracy • Accuracy is crucial when writing case notes. Remember, these documents can be subpoenaed. • Do not leave your statements open to interpretation. Be specific. Special Topic Module: Case Notes • Do not make comments that you would not want the client to read. • Do not make diagnoses or offer conclusions that you are not qualified to make.

16. II. Using Case Notes: 4. Brevity and Shorthand • Your note taking should be brief and not too time consuming. Special Topic Module: Case Notes • Using shorthand in your notes is fine as long as you include a key in each file. Otherwise, your notes are useless to others.

17. III. Case Note Guidelines G1. Date & Initial Everything G2. Using Quotations Special Topic Module: Case Notes G3. Pertinent Information G4. Specific, Observable and Measurable Terms G5. Your Opinions G6. Current Status

18. III. Case Note Guidelines: G1. Date & Initial Everything • All entries, even failed attempts to contact the client, should include date, time and initials. Special Topic Module: Case Notes • Keep in chronological order with most recent on top to maintain an organized and logical format. • Explain gaps in time. • Look for patterns that may develop.

19. III. Case Note Guidelines: G1. Date & Initial Everything cont… Peterson, Joel • 02/02/01 3:37 pm • I called Joel today. He said the job was going well. He is still attending AA meetings every Wednesday night and meeting with his physical therapist twice a month. We met next on 2/27/01 at 4 pm. • LB Special Topic Module: Case Notes

20. III. Case Note Guidelines: G2. Using Quotations • It is critical to use quotes when the client offers shocking, surprising or baffling information. Special Topic Module: Case Notes • Quotes must be kept in context. • Quotes give personality to the client and credibility to the note taker.

21. III. Case Note Guidelines: “I felt like strangling her!” G2. Using Quotations cont… • Quote the client when he or she says something out of character or that would impact job placement. Special Topic Module: Case Notes “I don’t really want to work.” “My husband left me and my children!”

22. III. Case Note Guidelines: G3. Pertinent Information • Focus on the client’s ability to obtain their goals. Special Topic Module: Case Notes • Any information which could impact their goals should also be considered pertinent.

23. III. Case Note Guidelines: G4. Specific, Observable and Measurable Terms • The most crucial skill of note taking is speaking in specific, observable and measurable terms. You don’t want to leave your comments open to interpretation. Special Topic Module: Case Notes • Don’t judge your client or make unprofessional or unsubstantiated comments about their lifestyle, appearance, personality or behavior.

24. III. Case Note Guidelines: G4. Specific, Observable and Measurable Terms cont… Non-Specific More Specific “He obviously has a drinking problem.” “Both times we met, he smelled of alcohol and stumbled when he walked.” Special Topic Module: Case Notes “She was late again today.” “She arrived 15 minutes late, saying she had car trouble.” “He was agitated and uncooperative.” “He shouted and jumped out of his seat several times. He refused to answer questions.”

25. III. Case Note Guidelines: G5. Your Opinions • If something is in your opinion, make sure you say so. Special Topic Module: Case Notes • Opinions should be used sparingly or not at all. • If you state your opinion, have some documented evidence to back it up.

26. III. Case Note Guidelines: Mr. Peters, in my opinion, is not yet ready to look for a job. He has several barriers (see IDP) that he needs to overcome before he is job ready. G5. Your Opinions cont… Special Topic Module: Case Notes

27. III. Case Note Guidelines: • Date and time of next appointment or phone call G6. Current Status • Before initialing your case note entry, include information regarding your next contact. For example: Special Topic Module: Case Notes • A note to remind yourself what you or the client plan to accomplish before the next meeting.

28. Case Notes for Frank Hogkins 4/4/00 Frank has made great progress the past two weeks. After completing his VR&E training, he attended our job search workshop and has already been interviewed for a computer programmer position. However, when asked how the interview went, Frank said, “He asked me some questions that I just didn’t know how to answer.” I have scheduled Frank to come in on Monday to watch the Ultimate Job Search: Interviewing with Confidence video. LB 3:00 pm Sample Case Notes Special Topic Module: Case Notes

29. Case Notes for Frank Hogkins 4/4/00 Frank has made great progress the past two weeks. After completing his VR&E training, he attended our job search workshop and has already been interviewed for a computer programmer position. However, when asked how the interview went, Frank said, “He asked me some questions that I just didn’t know how to answer.” I have scheduled Frank to come in on Monday to watch the Ultimate Job Search: Interviewing with Confidence video. LB 3:00 pm G 1 Sample Case Notes Special Topic Module: Case Notes G2 G6 G1

30. Case Notes 9/1/00 3:00 pm Joe Bishop -30% Disabled (shoulder injury) -Laid off from the mill -Worked 7 years grain elevator op. -Has wife and two kids -Accommodation- no heavy lifting -In my opinion, job ready -Referred to machine op. position at the dam. Interviews tomorrow. ZK Next appt. 9/5/00 2 pm Sample Case Notes Special Topic Module: Case Notes

31. Case Notes 9/1/00 3:00 pm Joe Bishop -30% Disabled (shoulder injury) -Laid off from the mill -Worked 7 years grain elevator op. -Has wife and two kids -Accommodation- no heavy lifting -In my opinion, job ready -Referred to machine op. position at the dam. Interviews tomorrow. ZK Next appt. 9/5/00 2 pm G1 G4 G3 Sample Case Notes Special Topic Module: Case Notes G5 G6 G1

32. Laura Bing ~ Case Notes 5/5/00 Laura is a 40 year old homeless woman who lost her last job in the food industry after suffering a mild stroke. She has lost partial use of her left arm. She said,“It is hard for me to lift things and I tire easily.” I had her apply for unemployment and have arranged for her to meet an occupational therapist at the VAMC next Tuesday. I also referred her to the parish homeless shelter until a spot becomes available in the VA facility and provided her with some bus passes to get around on. Look into disability options before next meeting on 5/10/00 at 4 pm. RJ 1-1:30 Sample Case Notes Special Topic Module: Case Notes

33. G6 Laura Bing ~ Case Notes 5/5/00 Laura is a 40 year old homeless woman who lost her last job in the food industry after suffering a mild stroke. She has lost partial use of her left arm. She said,“It is hard for me to lift things and I tire easily.” I had her apply for unemployment and have arranged for her to meet an occupational therapist at the VAMC next Tuesday. I also referred her to the parish homeless shelter until a spot becomes available in the VA facility and provided her with some bus passes to get around on. Look into disability options before next meeting on 5/10/00 at 4 pm. RJ G3/4 1-1:30 G3/4 G2 Sample Case Notes Special Topic Module: Case Notes G6 G1