The Art of Writing Case Notes This material

The Art of Writing Case Notes This material is licensed under the Creative Commons Attribution 4. 0 Unported License. To view a copy of this license, visit http: //creativecommons. org/licenses/by/4. 0. This workforce solution was funded by a grant awarded by the U. S. Department of Labor’s Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U. S. Department of labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership.

Why Maintain Case Notes on Participants/Students? The Workforce Innovation and Opportunity Act (WIOA) requires grantees to make real effort to collect data on all participants & employees.

Purpose of Case Notes • Case Notes record important details about services provided to the customers. • Case Notes are your way of letting the next reader know what is going on with the participant. • Case Notes serve to track the participants progress in the grant program. • Case Notes serve as documentation of key factors affecting the participant (eligibility, quality of service provided, whether service is effectively meeting the participant’s need any changes in the participant’s condition or circumstances that would warrant an adjustment in services provided).

Grant Participant Files with Case Notes may be paper files or electronic files.

Participant Outcomes Each grant has a set of performance measures it is trying to achieve. Case notes serve to support the performance reporting and monitoring. Grantees must document participant: – Start dates – Milestone progression & participant status – Individual & overall performance results – Service & program completion dates – Exit dates

Case Notes Should Always Include: ◦ Date of the note ◦ Method of contact (face to face, email, phone call) ◦ Name of the staff member making the note ◦ Description of the event ◦ Description of how the customer will benefit from the activities

Timelines • Update Case Notes Frequently and Promptly: • While the information is fresh in your mind. • Frequency makes it easier for someone else to pick up where you left off if you are called away from the case. • Case note any time there is interaction with customer, i. e. phone call, email, hallway or parking lot conversation, etc.

Professionalism • Avoid using slang, street language, clichés or jargon. Use professional terminology as well as correct capitalization and punctuation. • Avoid metaphors or similes; just say what you mean directly. • Do not write so cryptically that no one knows what your are writing. • Address the behavior. • Do not state participant is a victim of domestic violence. • Do not identify medical diagnosis. (HIPPA) • Omit details of client’s intimate lives that do not have an impact on their educational plan.

Writing Recommendations Write in a style that is: ◦ Factual - Accurate ◦ Objective; unbiased ◦ Specific ◦ Clear and to the point ◦ Initial and Date each entry

Specific, Observable & Measurable Pertinent Information • 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 student or make unprofessional or unsubstantiated comments about their lifestyle, appearance, personality or behavior.

Quality Control Supervisors might review your case notes to monitor progress. Auditors might review your case notes for compliance with state and federal policy and procedure. Remember, you never know who will be reading the case notes!

Warning! Possible Liability Issue ◦ Recording a “to do” item in the case file and not following through. ◦ Negative, biased or prejudicial language. ◦ Medical Conditions (consult your college student record policy)

Three Elements of a Good Case Note 1. FOCUS: John is an experienced nursing home janitor, recently unemployed and looking to stay within the health care industry. 2. SERVICE: I met with John 5/12/12 and we assessed his Work. Keys scores, enrollment application, his resume, and discussed his employment history and the skills that were developed with each job. I assisted John in making a decision to enroll in the Mo. Health. WINs environmental maintenance pathway of programs to begin 6/10/12 to give him additional industry credentials and access to the ABC Hospital partner who is in need of these skill sets. 3. NEXT STEP: I provided John with a list of up-coming grant portal orientation workshops, including digital literacy, I assisted John with scheduling himself to begin the 6/2/12 workshop, John will check back with me on 6/5/12.

Now Let’s Review a Few Case Note Examples!

Sample 1 • Mr. Miller met me in the hallway, he is currently working with Munroe Regional Medical Center. Provided Mr. Miller with my business card to stop in an see me to discuss the Mo. STEMWINs programs of study. • This case note is unacceptable. The information is lacking specifics such as focus, date, next steps, and who is the author of this case note.

Sample 2 Mary Awesome stopped by my office on 9/9/15 to inform me she has obtained employment with Aerotek as a bio med technician. Her dislocation wage prior to the Mo. STEMWINs program was $17. 30/hr and her new starting wage obtained is $18/hr, which is 104% of her dislocation wage. Mary plans to check back in March after her probationary period for future training opportunities in her field so she can advance. --DB, MSWINs Comm College Advisor 9/9/15 This case note is acceptable.

Sample 3 • Customer called to say that he would not make his appointment. • This case note is unacceptable. Who is the customer? When was the appointment? What was the appointment for? Was the appointment rescheduled?

Sample 4 John’s occupational goal is Physical Therapist. Participant has completed the eligibility process at the Jeff. City. Mo. Career. Center on 6/15/15, completed the college PT enrollment application and has been approved(see file documentation). John has been accepted at the MSWINs Comm College, total training cost is $12, 000(of this $6, 000 is non grant funded). Training program is on the ETPL list, is supported by the local LMI data, and WIB partner. Training is not FAFSA/Pell eligible. The WIB has APPROVED John’s non grant cost of $6000 on 6/30/15 for the full amount beginning on 8/15/15 for a 1 year training program from the Dislocated Worker funding stream. Will check back with John via email to verify his commitment for the August class start dates on August 1, 2015. His Jeff. City Career Center Case Mng is Sally Goodservice. --DB, MHWINs College Career Coach Advisor 7/1/15 This Case Note is Acceptable. The information is detailed and specific.

Sample 5 Participant Samantha Smith called, stated on 4/20/15 she has finished up all of her courses at MSWINs Comm College and will be emailing me copies of the certifications she has obtained since her last visit with me. In addition, she stated that her unemployment benefits have exhausted. She will be leaving town today, 05/09/15, for a few weeks, but upon her return she will take my advice and register with staffing agencies and come in for resume assistance/critiquing. -- DB, MHW College Retention Coach 4/20/15 This case note is acceptable.

Reminders • Case Notes: • Have a Purpose • Require Substance • Must Be Entered Timely • Always Display Professionalism • Quality Control – Fact. Checker’s

Thank you! Find out more at www. mowins. org Ms. Dawn Busick Statewide Grants Director dawn. busick@mccatoday. org 573 -634 -8787 This material is licensed under the Creative Commons Attribution 4. 0 Unported License. To view a copy of this license, visit http: //creativecommons. org/licenses/by/3. 0. This workforce product was funded by a grant awarded by the U. S. Department of Labor’s Employment and Training Administration. The product was created by the grantee and does not necessarily reflect the official position of the U. S. Department of labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership.