1. SPECIAL TOPICS MODULE CASE MANAGEMENT: CASE NOTES

2. S p e c i a l T o p i c M o d u l e : C a s e N o t e s OBJECTIVES The objectives of this module are to: I. Explain the function of case notes, II.Demonstrate the usage of case notes, and III. Present guidelines for writing effective case notes.

3. Special Topic Module: Case Notes 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. INTRODUCTION

4. Special Topic Module: Case Notes INTRODUCTION cont… 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.

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

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

7. Special Topic Module: Case Notes I. Functions of Case Notes: 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. 2. Clarification and Planning

8. Special Topic Module: Case Notes I. Functions of Case Notes: 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. 3. Tracking Progress

9. Special Topic Module: Case Notes I. Functions of Case Notes: 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). 4. IDP Adjustment

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

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

12. Special Topic Module: Case Notes II. Using Case Notes: It is important to inform your client why you are taking notes and how they will be used. 1. Informing Your Client 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. Special Topic Module: Case Notes II. Using Case Notes: Share your notes with the client. 1. Informing Your Client cont… o Your client should feel comfortable enough to share personal information with you. o Sharing instills a sense of control to the client that is vital to his or her progress and independence. o Working with the client helps you keep your notes honest and accurate.

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

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

16. Special Topic Module: Case Notes II. Using Case Notes: 4. Brevity and Shorthand Your note taking should be brief and not too time consuming. 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. Special Topic Module: Case Notes III. Case Note Guidelines G1. Date & Initial Everything G2. Using Quotations G3. Pertinent Information G4. Specific, Observable and Measurable Terms G5. Your Opinions G6. Current Status

18. Special Topic Module: Case Notes III. Case Note Guidelines: G1. Date & Initial Everything  All entries, even failed attempts to contact the client, should include date, time and initials.  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. Special Topic Module: Case Notes III. Case Note Guidelines: G1. Date & Initial Everything cont… 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 Peterson, Joel

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

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

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

23. Special Topic Module: Case Notes 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.  Don’t judge your client or make unprofessional or unsubstantiated comments about their lifestyle, appearance, personality or behavior.

24. Special Topic Module: Case Notes III. Case Note Guidelines: G4. Specific, Observable and Measurable Terms cont… Non-SpecificMore Specific “ He obviously has a drinking problem.” “Both times we met, he smelled of alcohol and stumbled when he walked.” “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. Special Topic Module: Case Notes III. Case Note Guidelines: G5. Your Opinions  If something is in your opinion, make sure you say so.  Opinions should be used sparingly or not at all.  If you state your opinion, have some documented evidence to back it up.

26. Special Topic Module: Case Notes III. Case Note Guidelines: G5. Your Opinions cont… 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.

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

28. Special Topic Module: Case Notes 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

29. Special Topic Module: Case Notes 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 G1G1 G2 G6 G1

30. Special Topic Module: Case Notes Sample Case Notes Case Notes 9/1/00 Joe Bishop -30% Disabled (shoulder injury) 3:00 pm -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

31. Special Topic Module: Case Notes Sample Case Notes Case Notes 9/1/00 Joe Bishop -30% Disabled (shoulder injury) 3:00 pm -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 G5 G6 G3

32. Special Topic Module: Case Notes Sample Case Notes 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 5/5/00 1-1:30 Laura Bing ~ Case Notes

33. Special Topic Module: Case Notes Sample Case Notes 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 5/5/00 1-1:30 Laura Bing ~ Case Notes G6 G1 G2 G6G6 G3/4