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Transcript of Case Management
Translation & Interpretation
1) "Mrs. Adams seemed irritable." vs.
"Mrs. Adams raised her voice when I asked if she had checked on Andy today. She also raised her voice and showed me a bottle with some milk in it when she was talking about Andy wasting milk."
Intake (inside left cover)
-Master Intake, Client Rights and Responsibilities, RFS release forms, case notes etc.
Employment (middle divider - left side)
-Employment Services forms, case notes, other related documentation/paperwork, etc.
Social Adjustment (middle divider - right side)
- Social Adjustment Services forms, case notes, related documentation, etc.
Information and Referral (inside right cover)
- Information and Referral Services forms, case notes, related documentation, etc.
Translation & Interpretation
Person responds freely, not restrictive answers, allows the client to share.
Best to use when you need elaboration and clarification of a situation.
Begin the question with what and how.
Examples: Tell me about your family. How do you feel about your new job? What computer skills do you have?
Prompts and Probes
Question formulation mistakes
Using both close-ended and open-ended questions should reflect the purpose of the contact.
Narrow focus, more direct, emphasis on a single answer (yes/no), results in a limited response.
Best to use when you need facts or identifying information.
Begin the question with did, have does, do, and is.
Examples: Who do you live with? Do you like your new job?
A prompt is a minimal signal, a gesture or vocalization, to encourage the speaker to continue.
Examples: head nod, "uh-huh" or "go on", repetition of key words ("unhappy?", "anxious?")
A probe is a question used to obtain more information and move the interaction along in a productive way.
How do you feel about the fact that...?
What was your reaction?
What do you think is best?
*These probes can also focus on significant others:
What was your son's reaction? What does your spouse think is best? etc.
Avoid leading or suggestive questions.
Didn't you call the police right away?
How did you respond to those awful comments?
Avoid asking irrelevant questions.
Changing topics abruptly (Worker's needs vs. Client's needs)
Avoid asking close-ended questions eliciting a yes or no answer.
Did the doctor say everything was okay? vs. What did the doctor tell you?
Avoid asking double or multiple questions.
What did you think of your job interview and what did they think of you?
Avoid asking why questions.
These questions tend to sound accusatory.
Example: Why did you go there? Why did you react like that?
Case/Progress Notes Outline
Case Note Organization
Documentation of worker activity
If it's not recorded, it never happened
Documentation shows who the agency serves and what services are provided
The case manager does not have to depend on her/his memory
Useful for supervisory review
Continuity of service
Documentation focuses on the client, not the worker
Used as a tool for continued service to a client when the client changes case managers/agency.
Payment for services
Verification that services were provided and payment can be received
Lack of documentation can prevent clients from receiving services
for which they are eligible
Justifies agency activities
Documentation of the nature of the demands for agency services, types of services provided, and the outcomes
Case notes should always include the following:
"Why am I writing this as it relates to the client's situation?" "Who will read it?"
Your documentation reflects your efforts to monitor the delivery service to your client.
- Keep summaries focused and to the point.
- Do a note for each missed session (client cancellations / no shows).
- Make sure your written record is legible and your name is legible.
- A written record should be as long as needed to achieve the main purpose of the recording.
- Avoid judgmental statements, subjective words, and generalizations.
- All statements should have evidence/facts to support the worker's assessment or impressions.
- Avoid hostility and frustration in your documentation.
- Always give the source of information when recording material from another person, agency, or record. Use quotation marks!
- Facts vs. Impressions
- Spelling and grammar checks
- Be careful with abbreviations (must be standardized and consistent).
- Written records are viewed as a reflection of the worker's skills.
1. Date and type of contact
Example: 3/8/05 (Office visit), 4/1/07 (Phone)
2. Purpose of the contact
Document who you had contact with: "Met with Ms. Adams at her home."
Document the purpose of the contact: "... to discuss her progress toward job readiness."
3. Brief summary of contact
Document important factual information
As appropriate, document significant aspects of the contact such as the person's behavior, facial expressions, appearance, affect, etc. :
"She appeared more confident in her ability to work full-time and eager to begin her job search."
4. Worker activity and action plan follow-up
Document what you have done and what you will do:
"Ms. Adams agreed to begin her job search next week and I gave her the name of a job placement agency. I will call her next week to follow-up and provide any needed support services."
- Data -
a factual description of the contact/meeting. This section is typically the largest portion of the note.
– Assessment – your evaluation of current status and progress toward meeting the client's goals in working toward self-sufficiency.
P – Plan – statements about what will happen next
2) "The house was very dirty." vs.
" There were old cigarette packs, trash, and empty pizza boxes on the floor of the home. There was trash on the sofa. "
3) "The crib was in disrepair." vs. "The side of the crib was broken and was a danger to Andy due to its sharp edges and lack of stability. If Andy were to roll over, he could fall right through the side of the crib."
4) "Mr. Adams seems isolated." vs. "Mr. Adams lives in an isolated area with no streetlights, or address signs. According to his neighbor Sam, Mr. Adams has no family support in the area.