2010 Case Noting Revised

ABC’s of Good Record Keeping:A Basic Refresher Course on

EI Case Management Documentation

Facilitated by:

Dawn Mastoridis,

Executive/State Director, RCDS/TMN

Oct. 1st 2010

Objectives of the Training Understand the context of Early

Intervention law & current regulatoryguidelines

Learn the importance of case notedocumentation within an EI Program

Clarify what information should beincluded in an EI record case notedocumentation

Tips & Techniques to a) improve thequality of your case notes, and b) waysto manage your time

What is Case Management?

Ongoing monitoring of services and servicecoordination

Ensure that quality service is being provided

Evaluating whether a service is effectively meetingthe participant’s need

Identify any changes in the participant’s condition orcircumstances that would warrant an adjustment tothe care plan.

Reflects what is happening withregard the agency’s efforts to provide& monitor EI service delivery

Provides required documentation tosupport case management activitieswithin the agency as per the Stateand/or local municipality regulatoryguidelines

Provides a measure of protection tothe agency, State funding entities &child’s family.

Why are Good Case NotesSo Important?

Individuals with DisabilitiesEducation Act (IDEA)-Part C

Federal grant programthat assists States inoperating an EarlyIntervention Program

Early Intervention Programmust be made available toevery eligible child

States have discretion insetting the criteria foreligibility

State Requirements

The child’s record must reflectthe agency’s efforts to complywith all aspects of servicedelivery as per the Federal &NYS Dept. of Health Guidelinesfor Individual with DisabilitiesEducation Act (IDEA-Part C)

State Recommendations

A case note should: Cite the date

Identify the people and relationship

Identify the type of contact – Face to face,phone conversation, etc.

Describe the event

Objectively recount the transaction

Demonstrate how the contact relates to servicedelivery and/or the child plan of care

Describe how the issue was resolved, and/ornext steps

Case Noting with Outcomes

in Mind

Case notes should reflect any work towardimplementing, monitoring, or any changesin an outcome.

Case notes should be written that reflectthe:

1) Progress or tracking of events

2) Who is responsible for doing what

Case Noting with Outcomesin Mind (continued)

Case notes will provide documentation that thecoordinator is focusing on the right thing –keeps you on target

It’s not about “checking in” – it’s about “Whatam I checking on”.

Case Note Differences

Case noting a contact:

Referral & intake

Phone, face-to-face, correspondence

Tracking the flow of events, outcomes

Case noting for documentation purposes:

Gaps in service delivery

Explanations for delay of services

Issues with authorizations

Reasons to Record All Activity

Leave a “paper-trail”

Provide verification ofactivity

Reminder to coordinatorof case context &required follow-up steps

Reference for potentiallegal or mediationissues

Help co-workers andsupervisors to addressissues when you are outof the office

To provide evidence ofagency’s efforts to meetall DOH compliancemandates

Warning

Possible Liability Issue

Recording a “to do” item in the case file and notfollowing through

Negative, biased, or prejudicial language

Keep in Mind

If you didn’t write it down, no one knows ithappened

Your records might be viewed by: Judges

Attorneys

Participant

Guardian

State Officials

Writing Recommendations

Write in a style that is:

Factual

Objective; unbiased

Specific

Clear and to the point

Other Writing Tips

Without jargon

Don’t write so cryptic that no one one knowswhat you are writing

Omit details of clients intimate lives that do nothave an impact on care plan

Avoid using medical terms or a diagnosis thathave not been verified

Case Note Exercise

Read the casenotes provided

Is the case noteacceptable?Complete? Why orwhy not?

Case Note Exercise #1

6/5/06

Talked to Sue. She said things are going well.

Answer to Case Note Exercise #1

Answer: No

Reason: Don’t know what type of contact occurred -a face-to-face?, telephone? Who is Sue? Limitedinformation.


6/5/06

Voice mail message from Margaret. She relayedthat Mrs. Roberts cancelled the PhysicalTherapist today because Johnny she was notfeeling well.


Answer: No

Reason: Who is Margaret?


6/5/06

Staffing Coordinator spoke with Peggy O’Brian- EIService Coordinator w/the agency We DoEverything. Peg relayed that Mrs. Robertscancelled Physical Therapy today because Johnnywas not feeling well. Peg relayed that Mrs.Roberts decided not to reschedule for anothertime this week. Mrs. Roberts said it was ok forthe PT to go see Johnny next week at the sametime.


Answer: Yes – this case note is acceptable.


6/5/06

Talked to Mrs. Roberts. She said things aregoing well. Johnny visited his grandmother’sover the weekend. Had a nice time.


Answer: No

Reason: Don’t know what type of contact occurred –face-to-face? telephone? No documentation tosuggest there was discussion about the parentregarding the child’s services, health or IFSP outcomesor other relevant case management activities.


6/5/06

Staffing Coordinator Spoke w/ Mrs. Roberts. Shesaid things are going well. ohnny visited hisgrandparents on Saturday afternoon and wasable to walk up the stairs to their apt withassistance. Mom reports Johnny remains in goodhealth. PT & OT are arriving as scheduled- shereported no problems w/ their services. Nextscheduled PT session is for 6/7/06 at 1:00 p.m.OT scheduled for 6/9/06 at 10 am.




6/5/06

Evaluation Coordinator spoke w/ Mrs. Roberts.She confirmed that the Speech Evaluator madean appt. to assess Johnny, tomorrow at theirapartment at 10:00 am.




6/5/06

OT reported conducting a home-based sessionwith Johnny today. Nice visit. Things are statusquo.


Answer: No

Information is limited. No information given regardingwhat was accomplished at this session. No informationgiven regarding the service plan outcomes, child’shealth, family needs, concerns or priorities, etc.


6/5/06

SW reported a session with Mrs. Roberts & Johnnytoday. SW states mother & child looked awful-clothes dirty, hair dirty, hair messed up. She stunk.The apartment smelled liked pee. As usual, shecomplained of not feeling good. SW told her to gosee her doctor. Will call EI SC to find out if sheknows anything about why Mrs. Roberts stinks.


Answer: No.

Reason: Unprofessional, biased


6/7/06

SW reported concerns following a session w/ Mrs. Roberts &Johnny today. SW stated that both child & parentappearance presented as unkempt- clothes stained, hair dirty& uncombed. Noticeable body odor. Apartment appearedneat & tidy although urine smell detected. This is the firsttime this SW has noticed the urine smell or seen Mrs. Robertsor child in this appearance in last two months. SW statedboth mother & child appeared alert & oriented during visit.Staffing Coordinator spoke with Mrs. Roberts who relayedher SW has been coming regularly and she is pleased withher services. Staffing Coordinator consulted with Supervisor& left message with SC to discuss follow-up plan on this case.


Answer: Yes – this case note is acceptable

Take Aways…

Case notes are lengthy when they are needed todocument all important information that wasobserved, or discussed

Case notes can be short, concise when that iswarranted

For Service Coordination there must be a logicalcorrelation between the amount of case managementbilled for a contact and what is documented in a casenote.

Tips & Techniques to Consider

Carry a note pad with you at all times

Keep a note pad near your phone

Save a half hour each day to do case noting

Develop an routine protocol

Set aside paperwork days and put it on your calendar

Re-evaluate current forms/templates - are there things thatcould make them easier?

Talk to a co-worker who does case noting well to learn fromhim/her

Secure protected time

Is it possible to turn your phone off for a half hour?

Say “no” to other tasks for a limited timeframe

In Summary

Why is Good Case Noting Important?

Provides a Picture

Provides Documentation

Provides Protection

Keeps you focused on what you are workingon and why

Questions?

Health & Medicine

2010 Case Noting Revised