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Presentation on theme: "D OCUMENTATION IN C LIENT F ILES & C ASE N ARRATIVE T RAINING 2010 Case Manager Training."— Presentation transcript:


2 C LIENT F ILES 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 C LIENT F ILE 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 M ONITORING S TAFF 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 W HY 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 P URPOSE OF C LIENT F ILES 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 I NITIAL C ASE N OTES / C ASE N ARRATIVE 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 C ASE N OTE /C ASE N ARRATIVE 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 C ASE N OTES / C ASE N ARRATIVE 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 I NITIAL C ASE N OTE / C ASE N ARRATIVE 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 I NITIAL C ASE N OTE / C ASE N ARRATIVE 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 A NNUAL C ASE N OTES 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 I NTERIM C ASE N OTES 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 I NTERIM C ASE N OTES 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 D OCUMENTATION 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 R EMEMBER 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!!


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