Fundamentals of Case Management Practice: Skills for the Human Services, Third Edition Chapter Twenty-four Making the Referral and Assembling the Record

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Fundamentals of Case Management PracticeSkills
for the Human Services, Third EditionChapter
Twenty-fourMaking the Referral and Assembling
the Record

• By
• Nancy Summers
• Published by
• Brooks Cole
• Cengage Learning
• 2009

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RECORD KEEPING

• Document all contacts with clients or related to
  your client.
• This is done for both legal and administrative
  reasons.
• Legally it shows you are providing the service
  for which you are being paid.
• Administratively the record is a document of the
  activities and contacts related to your client.
• The notes should focus on the client and not on
  you.
• The purpose of the record is to keep the record
  current.

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WRITING CONTACT NOTES

• Contact notes written in the chart should always
  include the following
• 1. The focus of the interview.
• 2. Your assessment based on a concise summary
  of behavior, appearance, affect.
• 3. Any resolution that takes place.
• 4. The reason for the next contact or the
  follow-up that will occur.

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SAMPLE CONTACT NOTE

• Focus of the Interview
• Betty came into the office today to discuss her
  pending discharge from the inpatient unit.
• The Assessment
• she seemed anxious about leaving and worried
  about remaining clean without adequate
  support,although she left somewhat relieved at
  the plans in place for her.
• The Resolution
• Betty chose an AA meeting site and will attend
  90 meetings in 90 days. She was told that she
  will be referred to out patient group counseling
  and have a therapist the first 8 weeks after
  discharge.
• The Follow-up
• C.M. will contact Betty next week to see how she
  is doing with the outpatient support.

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LABELING THE CONTACT

• All contact notes should be dated and labeled.
• EXAMPLE
• 4/16/09 (phone)
• There are a number of labels you can use
• Collateral - contact with someone relevant to the
  client but not the client.
• Office visit - client came to the office.
• Phone - you and the client spoke on the phone.
• Site visit - you visited the client at the
  provider agency.
• Group - you saw the client in a group setting.
• Home visit - you visited the client in his or her
  home.

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GOOD DOCUMENTATION I

• Avoid hostility - do not use your notes to vent
  hostility about the client
• Document interactions with the client - document
  the interaction between you and the client.
• Document significant aspects of the contact -
  significant aspects give clues to the clients
  state of mind and the problems faced. Document
  appearance, facial expression and mannerisms,
  responses to others or to activities, attitudes,
  and cognitive problems.
• Be clear and precise - refrain from using general
  or vague terms. Rather than Bill was upset
  today use Bill was upset today over the
  possibility that he may lose his job.

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GOOD DOCUMENTATION II

• Use quotations - The rule is only the exact words
  spoken by the client go in quotation marks. If
  you paraphrase do not use quotation marks.
• Avoid contradictions - your program note must not
  contradict previous notes without explanation as
  to what has changed.
• Use language the client can understand - Avoid
  jargon used by professionals and write your notes
  in language the client and the family can
  understand.
• Accurately describe disabilities - rather than
  use terms like afflicted with, cripple, victim,
  confined to a wheelchair, handicapped, blind,
  deaf, and dumb, use expressions like a person
  with., uses a wheelchair, has partial sight, is
  hard of hearing or has partial hearing loss,
  nonverbal.

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GOOD DOCUMENTATION III

• Refrain from using judgmental words to describe
  the client - some words are more judgmental than
  others. For example dirty is more judgmental
  than unclean or nasty is more judgmental than
  unpleasant.
• Distinguish between facts and impressions - do
  not state something as fact that you do not know
  first hand to be true. Instead use terms like
  according to client or client seemed. or
  staff felt that client.
• Give a balanced view of the client - do not paint
  the client as entirely positive or negative.
• Provide evidence that you and the provider are in
  agreement - Your notes should indicate that you
  have met with providers, attended planning
  meetings and worked with providers

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GOVERNMENT REQUIREMENTS

• Use black ink as blue ink does not copy well
• Never use pencil of correction fluid
• The notes must be legible
• The clients name must be on each page
• Put the date of the actual contact in the margin
• Sign every note with the date it was written
• Notes should indicate what the follow-up with the
  client will be
• To correct a mistake
• 1. Draw a line through the error
• 2. Write error above the line
• 3. Write the correction next to the word error
• 4. Sign or initial and date the line

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MAKING CHANGES TO THE PLAN

• Often plans have to be changed or revised.
• This can be for a number of reasons, such as the
  client became ill, the provider closed for snow
  or overcrowding, the client had a death in the
  family, the plan is too difficult, the plan is
  not addressing the real issue, there are new more
  pressing issues.
• When the plan needs to be changed
• 1. Note the lack of progress toward the goals
• 2. State why
• 3. Note the revisions to the plan
• 4. Revise the actual treatment or service plan