Case Progress Notes: C reating P rofessional N arratives

1. Case Progress Notes:Creating Professional Narratives PA Office of Vocational Rehabilitation

2. Overview • Background information: • Why is case documentation important? • Casework processes: • How is case progression documented? • Quality standards: • What are the essentials? • Ethics & confidentiality: • What is the impact on case documentation? • Policy & program guidelines: • What factors are specific to PA OVR? • CPNs Specific to Case Status: • How is case progression documented? • Legal considerations: • What is the impact on case documentation? • Creating Professional Narratives: • Examples of case documentation

3. Who creates CPNs? • Throughout this training, the following OVR programs are referenced, as there may be similarities and differences in case documentation processes: • Vocational rehabilitation program (VR) • Independent living services program (IL) • Specialized services program (SS)

4. Who creates CPNs? • This training targets those OVR staff within the agency that are responsible for creating CPNs: • VR Counselors (BVRS & BBVS) • OVR Management Staff (BVRS & BBVS) • VR Employment Facilitator/Placement Counselor(BVRS) • Social Workers (BBVS) • Orientation & Mobility Instructors (BBVS) • Rehabilitation Teachers (BBVS) • Therefore, if the information applies to all of the positions stated above, “OVR staff” is utilized. If it applies to a specific program or position, these details are referenced.

5. Background information Why is Case Documentation Important?

6. Why is Case Documentation Important? Effective documentation: • Evidences positive customer outcomes • Records case progression, processes events for OVR professionals, customers and supervisors • Complies with state & federal laws & Rehabilitation Service Administration regulations • Promotes statewide uniformity and consistency to meet quality standards required in the case review process

7. Case notes serve several purposes • As a repository of information on customers • Provides evidence of ongoing comprehensive assessment • Provides an objective account (tells the story) of case progression

8. Case notes serve several purposes • As a means of tracking a customer’s progress through the vocational rehabilitation (VR), independent living (IL) and specialized services (SS) processes by presenting a picture of measurable/ observable events that have happened, that are happening, and that are being planned

9. Casework Processes How is case progression documented?

10. Guidelines to apply to case note documentation •  Case notes must be in the record (the electronic or hard copy file) as soon as possible after a contact or case activity occurs.   • Best practice – enter case notes within 24 hours of the contact to better ensure accuracy.  The longer the lapse of time before the case note is created, the greater the likelihood that important details will be forgotten.  

11. Guidelines to apply to case note documentation Case notes must: • Synthesize information • Document important events to justify actions taken • Synthesize progress or lack of progress toward achievement of the rehabilitation goal.

12. Recording case progress/changes Case notes provide information to assess:    • the planning process in the case;    • progress or lack of progress in the rehabilitation plan; and   • compliance with the vocational rehabilitation (VR), independent living (IL) and specialized services (SS) processes, policies and guidelines.   

13. Recording case progress Case notes document: • When case decisions are made • Why case decisions are made • Complicated or confusing billing problems or issues • Services authorized which are not on the original plan and are covered on a plan amendment • Unique situations or any special circumstances

14. Recording case progress • To explain rationale for and significant findings from evaluations, assessments or medical appointments • Summary of counseling and guidance sessions • CAP contact/involvement • Employer contact when specific to a customer

15. Quality standards What are the essentials?

16. CPN Format Styles • There are established quality standards and formats for case documentation. • SOAP (Subjective, Objective, Assessment, Plan) is a commonly used format for rehabilitation case documentation. SOAP format provides a means to: • organize information • promote critical thinking to analyze data and plan comprehensive case progression • “tell the story” of case development.

17. CPN Format Style - DATA Subjective and Objective Information or data Subjective data encompasses the perspective(s) of the customer and others affiliated in a non-professional association with the customer. Objective data includes professional observations, analysis, reports, findings, etc. SOAP summarizes critical thinking regarding customer problems or issues. It includes: Differential versus working diagnosis Level of customer cooperation/ insight/ motivation Behavior patterns that need to be addressed customer progress or lack of progress Efficacy of any treatments, services or plans

18. SOAP - ASSESSMENT • Summarizes “critical thinking” regarding customer issues or what occurred during a session. • State differential and/or working disability(ies) • Can discuss customer’s progress or lack of progress and related circumstances

19. SOAP - PLAN • Identifies the next steps that are planned in the rehabilitation process. • This can include: -Summary of what transpired during current session - Plans for the next meeting, including date and time - Identification of roles and responsibilities associated with any action plans (who does what and when)

20. CPN Format Style: Example SOAP Met with Mr. Holland on this date to review his input regarding his disability. Mr. Holland stated he has difficulty maintaining focus on tasks and reading and understanding written information. (Subjective) Results of psychological report by Dr. Martin diagnosed Mr. Holland with ADD, inattentive type. Specific learning disability was ruled out. (Objective) Findings are consistent with Mr. Holland’s self-reported behavior functional limitations. (Assessment) Eligibility determination is planned based on customer interview and psychological assessment findings. (Plan)

21. How To Write a CPN A CPN is written from the perspective that if published in a newspaper, the content would be accurate and understandable. If you retire tomorrow, another counselor should be able to pick up your case and be able to tell what is going on with each individual Include objective, relevant information with minimal opinion Include full names and titles of professionals referenced in CPNs Include full names and the relationship to the customer of relatives, friends and individuals. Explain any unfamiliar abbreviations.

22. General Content • When the contact was made (month/day/year) and if appropriate, the time • Who was contacted • Purpose of contact • What occurred • Plans for future action • “Signature” of who created the CPN (requested when typing CPN within CWDS) • If relevant, where the contact occurred (home, business, CareerLink, by telephone, etc.)

23. CPNs: Descriptions, not Opinions, Do NOT Diagnose • Include only relative material with minimal opinion-Do Not Diagnose • Describe behaviors • Describe dress/appearance • Describe affect Consider: • If subpoenaed, opinions could be used against the case note author • Customers may access to the case file and read CPNs

24. How to write a CPN -Considerations for Readability • Write a CPN from the perspective that others, including the customer, may be reading it. • Always include the contact date, customer name and author’s name. • Be specific and clear when entering the title of the CPN. CPN titles reflect the content of the note. • Use appropriate abbreviations. • Always use professional grammar – not jargon

25. Ethics & confidentiality What is the impact on case documentation? Source: Commission on Rehabilitation Counseling Certification Code of Ethics, http://www.crccertification.com/pages/crc_ccrc_code_of_ethics/10.php

26. Webster's dictionary describes ethics as: A set of moral principles or values The principles of conduct governing an individual or group Two part definition: One governed by our own values and sense of morality The other by the rules of conduct of our profession and the state in which we work What is Ethics?

27. Ethical Responsible for Case Documentation • It’s important to revisit the ethical principles within the context of case documentation.

28. Ethical Principles within the Context of Case Documentation • Autonomy: To respect the rights of the customer to be self-governing within their social and cultural framework. • Objective and respectful language about the client • Acknowledgement of cultural factors, without imposing values and judgment • Documentation of informed choice

29. Ethical Principles within the Context of Case Documentation • Beneficence: To do good to others; to promote the well-being of customers AND Nonmaleficence: To do no harm to others. •  Objective documentation of the facts to promote continuity of services, avoiding subjective information • Timely documentation to accurately reflect case progress • Inclusion of information relevant to the client, avoid inappropriate or unnecessary information

30. Ethical Principles within the Context of Case Documentation • Justice: To be fair in the treatment of all clients; to provide appropriate services to all. • If dual relationships are present, documentation of action taken by the OVR professional to address the potential issues • Documentation of objective information shared with the customer regarding choices and options

31. Ethical Principles within the Context of Case Documentation • Veracity: To be honest AND Fidelity: To be faithful; to keep promises and honor the trust placed in you. • Documentation of information shared with the customer regarding eligibility determination, order of selection, waiting lists, development and implementation of the plan of service and rights and responsibilities. This documentation should ensure that promises are not made that are not within the scope of the program. • Documentation of roles and responsibilities of both the OVR professional and customer, to ensure false promises are not made.

32. Ethical Responsibility of Case Documentation • DUAL RELATIONSHIPS: There are times when OVR professionals are faced with dual relationships with customers, which contains both personal and professional components to the relationship. • It is important to document your precautionary actions while engaged in an unavoidable dual relationship, to avoid risk that charges of exploitation would be upheld and to ensure customer’s fair treatment and confidentiality.

33. Documentation of an Ethical Dilemma • It is important to objectively document information about the ethical dilemma and its resolution, when the OVR professional is faced with an ethical dilemma. • An ethical dilemma occurs when a choice must be made between two or more courses of action, there are significant consequences are present for taking either course of action, and each course of action can be supported by one or more of the ethical principles. The ethical principles supporting the course of action not chosen are compromised to a degree. • The OVR professional should document the course of action take to resolve the dilemma (e.g. consultation with supervisor) and decisions made.

34. Ethical Responsibility of Case Documentation • ACCURACY: VR professions should maintain documentation that accurately reflects the services provided and that identifies who provided the service. • If case notes need to be altered, it will be done so in a manner that preserves the original note and will be accompanied by the date of change, information that identifies who made the change, and the rationale for the change. – check with Ryan re CWDS

35. Ethical Responsibility of Case Documentation • TIMELINESS: OVR professionals should provide sufficient documentation in a timely manner (e.g., case notes, reports, plans). If more than several days go by, it might be difficult to accurately remember significant details. • PRIVACY: Documentation generated by OVR professionals will protect the privacy of customers to the extent that it is possible and appropriate, and will include only relevant information.

36. Ethical Responsibility of Case Documentation • Document Decisions: It is important to document all decisions affecting customers within the case record. One must be sure that case recording covers the process used to arrive at a decision. Notes should be included about consultations sought and communications with the customers about decisions and actions that affect him or her must be documented.

37. Confidentiality of Case Documentation • OVR professionals are responsible for securing the safety and confidentiality of any records, whether they create, maintain, transfer, or destroy them. This applies to records that are written, taped, computerized or stored in any other media.

38. Customer Access to Case Documentation • OVR professionals should recognize that records are kept for the benefit of customers. • In instances where the records contain information that may be sensitive or detrimental to the customers, the OVR professional has a responsibility to adequately interpret such information to the customer and to provide case information in compliance with OVR policy. • (CITE SPECIFIC POLICY)IS THIS SLIDE NEEDED?

39. Confidentiality and Electronic Communication • OVR professionals should discuss with the customer and document information to adequately address and explain the limits of: • computer technology in the counseling process in general; and • the difficulties of ensuring complete client confidentiality of information transmitted through electronic communication over the Internet through on-line counseling.

40. Confidentiality and Electronic Communication • OVR professionals should take precautions to ensure and maintain the confidentiality of information transmitted to other parties through the use of computers, electronic mail, facsimile machines, telephones and telephone answering machines, and other electronic or computer technology. Disclosure of identifying information should be avoided whenever possible.

41. Confidentiality of Electronic Communication • SECURITY: OVR professionals should use encryption methods whenever possible. If encryption is not made available to clients, clients must be informed of the potential hazards of unsecured communication on the Internet. Hazards may include authorized or unauthorized monitoring of transmissions and/or records of sessions. Check with Ryan on this – email encryption.

42. Use of Electronic Communication as Case Documentation • RECORDS MANAGEMENT- • Electronic messages are considered to be part of the records of customers. Since electronic records are preserved, rehabilitation counselors inform clients of the retention method and period, of who has access to the records, and how the records are destroyed. – check with Ryan Source: Commission on Rehabilitation Counseling Certification Draft/Revised Code of Ethics, http://www.crccertification.com/filebin/pdf/CRCC_DraftRev_COE200903.pdf

43. Use of Electronic Communication in Case Documentation • If you are documenting appointment times, services and follow-up objectively, these emails are the exception and can be used as case documentation. • Otherwise, summary information communicated in an email in a CPNs especially when: • Multiple customers mentioned in the same email when speaking to a vendor, for example • String of emails, when the majority of content does not add value to the case; i.e., going back and forth to schedule an appointment • Emotionally charged, subjective language is used (e.g., use of profanity or abusive language) • Includes both management and case issues • What about emails from customers and other agencies and/or providers??

44. Policy & program guideline considerations What factors are specific to PA OVR?

45. Policy & program guideline considerations • OVR’s policies and program guidelines are defined in OVR memorandums. Some require specific CPN documentation. These are: • Job coaching • Extended services • On-the-job training • Financial needs test • HGAC • Independent Living/Specialized Services • Link to the OVR Numbered Memorandum system • Refer to OVR “Back to Basics” and “Basics and Beyond” trainings for case documentation specific to eligibility, IPE and case closure requirements.

46. OVR Numbered Memorandums-Job coaching Job Coaching CPNs must include: • Need for job coaching based on comprehensive assessment • Community Based Work Assessment • Anticipated results • How outcomes will be used in the vocational rehabilitation process • Extended Services Need for the service Establish OVR as sole payee Specify length of services

47. Extended services • Address MH/MR funding or ineligibility/lack of funding for extended services

48. On the job training • Document customer need for additional work skills to meet job requirements. • Include summary of proposed on the job training • Include evaluation of existing vocational skills, aptitudes, past work experiences. • Include statement that employer expects to retain employee in permanent status.

49. Financial Needs Test • Note any exceptional financial circumstances in a CPN. Examples: • Emancipated minor – parental income not included. • Significant change in financial circumstances such as layoff or recent high medical expenses. • Refusal to provide income information and implications for (cost) services.

50. HGAC specific CPNs • Hiram G Andrews Center staff utilize CPNs to compile a “running record”. Documentation occurs at least every 2 months. It includes: Summary Customer Input Counselor Impressions Goals