Case Management Process n n n n n

Case Management Process n n n n n Meeting Client/Initial Interview & Contact Mental Status assessment/document Releases/Informed Consent/Legal Service Plan Development Case Presentation Referral process Monitoring Contact Notes/Documentation Termination/Discharge

Case Management Mental Status assessment n n n n General Appearance Emotions Cognitive Functioning Thought & perception Suicidality, homicidality, impulse control Insight & judgment Reliability

Case Management Common Terms: n n n n Primary Language Presenting Problem Past Psychiatric History Functional Ability Moods/Emotions Physiologic Thinking Perception orientation/cognition/memory

Case Management Monitoring of Cases n n You are responsible for deciding the services a client will receive, based on the goals in the Service Plan You are responsible for the monitoring of the services w w n Quality of service Target behaviors/plan is currently addressed Progress reports Client is meeting target milestones/benchmarks? On Site, phone, written report, interviews

Case Management Contact Notes n n n Always to include. The focus of the interview Your assessment based on behavior, appearance, affect Resolutions Follow-up that is planned

Case Management Contact Notes (contd. ) n n Include Date and type of contact Types of Contact: w Collateral w Office w Phone w Site visit w Group w Home visit

Case Management Contact Notes-Tips n n n Be objective Include significant information Be specific Quotations Language Disabilities

Case Management Contact Notes-Common rules n n n n Black ink Legible Use Client’s name/DOB (sometimes client ID# is appropriate) Date of contact Case Manager’s signature Date your signature Line-out mistakes No blank lines

Case Management Text project on Pages 292 -298