Writing Effective Case Notes Beverly O Ford Ph

Writing Effective Case Notes Beverly O. Ford, Ph. D

Resource Chapter 7 Second Edition Making Case Management Work Handbook

What Are Case Notes? • Participant’s Journey through Process • Your Efforts to Impact Participant’s Progress

Assessment ØMotivators Ø Strengths Ø Barriers Ø Resources

Sample Assessment Case Note Motivators: hates living with sister, enroll daughter, Tasha, in cheerleading, help grandmother. Strengths: 3 years work experience, enrolled in GED, completed drug rehab Barriers: no reliable transportation, child care for 1 year old. Resources: sister, children’s father, church

Planning Steps to Move Participant to Employment How Plan Was Developed §GOALS §ACTION STEPS § TIMETABLES § RESPONSIBILITIES

SAMPLE PLANNING CASE NOTE Participant set initial goal of enrolling in CNA program. Participant suggested contacting friend to find out what she needs for enrollment. Explored who could be her supporters – grandmother, church members. Participant made to do list for the next week. Says she wants to do this to make better life for children.

Arranging Resources Used to Support Employment Plan §Partnership of Resources §Participant Resources First §Your Resources as Back Up

SAMPLE ARRANGING RESOURCES CASE NOTE Participant concerned about finding child care for 2 year old. Participant suggested talking to grandmother, people at church. CM will check on help from program. Will follow up in three days.

Follow Up • Participant’s Progress in Implementing Plan • Successes and Problems • Your Strategies for Influencing Participant’s Progress

SAMPLE FOLLOW UP CASE NOTE Contacted participant to review progress. Successes: Participant has contacted GED site; gotten children’s grandmother to be back up emergency childcare; found a friend who can give her rides sometimes. Problems: Consistent transportation and childcare. Action: Arranging transportation voucher and childcare assistance. to support participant’s efforts.

Case Notes Written for You ØOrganize = Summarize Essential Information ØAnalyze = Interpret Information ØPlan = Develop Strategies to Impact Outcomes

HOW DO I RECORD?

Information Connected to Program Goals A. Participant says he has no family support. Says family favors older brother and this make him sad. B. Participant says he has no family support. Discussed who else might provide support to help him look for work.

Avoid Duplicating Information ØParticipant is a 23 year old mother of 3 children. ØParticipant has worked as a welder and construction assistant.

Separate Fact and Opinion Facts = What You Know ØParticipant Tells You ØYour Observation ØInformation from other sources

Opinion = What You Think Use words to indicate what you think ØJohn seems unsure about going to training. ØSandra strongest motivator appears to be moving children to a better place

Fact or Opinion? A. Participant is unmotivated. B. Participant does not follow through with plans she makes.

Your Plan Passive Case Managers Wait and Hope Outcomes Happen. Active Case Managers Work to Influence Outcomes.

Active or Passive? A. Participant will begin work experience Monday. B. Participant begins work experience Monday. Will contact her next week to check on support systems for childcare and transportation; reinforce goals she set; praise accomplishments.

Confidentiality Summarize confidential information rather than recording it in detail. Example: Participant reported problem with physically abusive spouse. We discussed options for dealing with problem. Made referral to Domestic Violence Program.

Listen to Your Case Notes

Am I Actively Engaging Participants? Initial meeting with participant. Told her about our program and what she needs to do to get started. Told her about supportive services and what she is eligible for.

Am I Asking Open or Closed Questions? Participant says she has reliable childcare. Participant says she can ask mom, sister, and neighbor to help with childcare.

Am I Finding Participant Motivators? Participant is unmotivated. Says he wants to work but makes no efforts to do job search.

Am I Doing Too Much? Gave participant transportation voucher. Told him where he can get an interview outfit.

Am I Finding and Using Participant Strengths? Participant has little work experience, has not completed high school, and has a criminal record.

Confidentiality Summarize confidential information rather than recording it in detail. Example: Participant reported problem with physically abusive spouse. We discussed options for dealing with problem. Made referral to Domestic Violence Program.

Practice Exercise: Fact or Opinion Identify whether the following case note statements are fact (F) or opinion (O): O F O 1. Participant has mental health problems. 2. Participant says she is ready to make changes. 3. Participant appears stressed by all the problems she has. 4. Participant says she has drinking problem. F 5. Participant is lazy and unmotivated. O 6. Probation officer reports participant is using drugs again. F

Practice Exercise: Recording Your Process Which of the following are examples of the Case Manager’s Plan? 1. Participant will begin work experience on Monday. 2. Will contact participant before start of work experience to discuss her readiness to get started. 3. Participant seems unsure about how she will manage work and children. 4. Contacted participant to discuss strategies for managing work and children. 5. Participant says he has job interview next week. 6. Contacted participant to discuss preparation for job interview.

Practice Exercise: What to Include in Case Notes Which of the following should you include in your case notes? _____________________________ 1. Participant is a 23 -year-old mother of three children. 2. Participant says she is tired of getting public assistance—not enough money, people in your business, forced to do stuff, etc. 3. Participant did not complete high school. 4. Participant starting school; seems unsure about placing child in daycare. 5. Participant last worked as a warehouse stocker for six months. 6. Participant says he will ask sister and aunt for help with interview clothes.

Practice Exercise: Listening to Case Notes What are these case notes telling you about your process? 1. Participant says he has reliable transportation to get to class. 2. I will contact participant’s landlord to see what he can do about the problem with his apartment. 3. Told participant she needs to set goals to be successful. She says she is okay with where she is now. 4. Participant has significant barriers to participation. Explained how our resources can help her.

Questions?