Tips for Excellent Case Notes and Guardian Reports
Create standardized, professional, and comprehensive case notes by following best practices. Keep the style formal, factual, and observational without including personal opinions or emotional content. Ensure each case note is connected and adds valuable information to the preceding note, maintaining a clear linkage. Document physical, psychological, social, environmental, and financial aspects. Track contacts, record facts, establish policy compliance, and demonstrate quality casework through organized, detailed, and specific content. Your goal is to provide comprehensive information for various readers in a clear and understandable manner.
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Presentation Transcript
Tips for Excellent Case Notes and Guardian Reports
Best Practice Information in this presentation are suggestions for best practice and do not represent any DARS requirement. Each organization has their own policies and expectations for case notes. These guidelines are used at Jewish Family Service of Tidewater, Inc.
Case Notes Standardized and professional style Comprehensive in content Each case note adds information from the preceding note. There is an obvious link or follow- up from the information in the prior contact.
Standardized Professional Style Uses a consistent style of writing Do not use I or first person in writing (CM Pierce) Do not use client s first name or nickname (Ms. Jones) Record relevant information only Record observations, not unsupported conclusions
Comprehensive in Content Physical Psychological Social Environmental Financial
Connecting the Case Notes There is an obvious linkage between each case note. For example: 9/10/2020 Entry: CM visited Ms. Smith who reported that she needed new slippers, size 8. 9/15/2020 Entry: Delivered new slippers to Ms. Smith.
Purposes of Documentation Track contacts Record facts Establish policy compliance Comparative information over the life span of the case Demonstrate quality casework
Goals of Documentation Case notes should provide comprehensive information about the case. Your readers include: Next assigned worker On-call worker Supervisor DARS Review LDSS Guardian Report Court
Style and Content Formal writing, not conversational Not a diary and not emotional Fact-based information Observational, not worker s unsupported conclusions or opinions Organized and understandable Detailed and specific
Professional writing uses specific descriptions and observations to support a conclusion. Ms. Jones refused her meals and her medication for November 1-2, 2018, per RN Keller. RN Keller reported that client has lost 10 pounds this month. CM requested a medical and psychological assessment from the facility physician to rule out any underlying physical or psychological cause. Assessment to be completed 11/5/2020. CM will follow-up on 11/6/2020 to check on client status.
Why is this note good? Specific dates Specific facility contact person Plan of action Follow-up plan
Same information, but a different Case Note I am very worried since Ms. Jones has not eaten for two days. I think she may be depressed. She has also refused her medications! I am extremely concerned about her. I like her very much. What s missing in this Case Note?
Avoid amplifiers Very Extremely Exceedingly Enormous Awfully, terribly Exceptionally Instead, use specific descriptions and observations.
Avoid Absolutes Never Always Completely Instead, use specific facts and observations. For example: Ms. Jones son has not visited since December 2019.
Avoid Unsupported Statements Ms. Poe is a hoarder. Is this a formal diagnosis? What makes you think that? Observations Photographs Information provided by other professionals, family or friends.
Bias Bias in our case notes can be positive or negative. Usually identifiable by judgmental words: Extremely filthy Always drunk Rude and mean Really crazy Always so sweet
Avoiding Bias Do your case notes reflect your personal feelings, positive or negative? (Unsupported by observations or facts) Are your case notes about the client, or are they about your feelings or reaction to the contact? Re-read your Case Notes consistently after writing them to look for bias.
Case Notes Documentation reflects neutral observations and a description of the facts, without emotion or unsupported conclusions. Including five consistent domains of information provides a structure for Case Notes
Five Domains Physical Diagnosis, med changes, level of care or other assessments, ADL support, mobility Psychological Behavior, mood, medications, interventions, confusion, aggression, supervision needs
Five Domains (Continued) Social Recreational activities, watching TV, books, coloring, walking around the facility, facility activities, day program Environmental (Living Arrangement) Correct level of care? Setting adequate to meet client needs? Financial Income, Medicaid, facility bill paid, remain under resource limit Financial is the only domain not included on the Guardian Report
What should not be included in Case Notes? Worker s own emotional feelings (It s not about you!) The family had all of the usual excuses. They make me so angry! Instead, use factual information: The son John Smith was called 6 times about his mother s request to visit. To date, he has not called back. Information not relevant to the case Is this information important to know for case management? (e.g., Ms. Smith s favorite color is blue.)
What should not be included in Case Notes? Unsupported opinions or conclusions Ms. Brown is depressed. (Conclusion without any supporting information) or Ms. Brown needs an assessment for possible depression. RN Morse reported that client is not sleeping, eating about 15% of each meal, and has decreased her social contact.
Lets practice with some examples Can you identify suggestions to improve each of these case notes? Look at the content. Is it specific and detailed? Is there any bias or unprofessional writing style?
CM Smith spoke with the therapist on Tuesday. She reported that Jane has been in treatment with her for three months. I told Jim that I interviewed his father, Brian, at the hospital. He told me that he hit him when he found out about it. Mr. Lee is very frail.
CM Hill met Shorty at his usual place under the pier. CM Watts talked with CM Reilly who stated that this case is a hot mess and all the services in the world will not help him. CM Walker met with client who was rude and used curse words. His behavior was very upsetting to me.
Client fell. As usual, Mr. Keller was late for his appointment. He has always been uncooperative and hard to work with. Ms. Deer was pleasant during our visit. She is a deer to work with! Johnny ran away again. CM Brown will start looking for him tomorrow.
Consider, Who? What? When? Why? How? What would the reader need to know?
Which note gives the reader better information? Why? Ms. Garcia was extremely sad and upset when discussing the incident. Ms. Garcia began to cry, and started trembling, when asked to describe the incident. She took several deep breaths, and was silent for over 30 seconds before stating that she could not forgive her daughter.
Guardian Reports Read each question and respond to all parts of the question Use formal writing Detailed and specific Comprehensive, with current and accurate information Avoid unsupported statements
Lets practice! Let s look at two Guardian Report samples for the same client. Compare the quality and style of the information provided. Who might have questions about the report? Supervisor Next assigned worker LDSS Court
Thanks! Thanks for participating in this webinar. Talk with your Supervisor about the application of these ideas in your own case notes.
