1 Improving Services and Performance Toolkit for Effective Front-line Services to Youth Module Six: Documentation: Record- keeping, and Case Notes

2 Module Objectives To demonstrate how the case record is used to provide program accountability, as well as documenting a young person’s achievements To stress the importance of timely, concise, accurate, standardized records and case notes To describe issues of confidentiality

3 Purposes and Types of Records Accurate record keeping supports the case manager in planning, implementing, and evaluating services for each young person Accountability to the young person, the organization and the funder Types of records in a case file (electronic/paper or both): - eligibility documents - assessment documents - plans (ISS) - records of activities - documentation of credentials - outcomes - case notes See examples in the Manual

4 Case Notes Record results from a face-to-face meeting or conversation or a significant event regarding the participant’s life or progress in the program. Include: Description of the context Purpose of the conversation Observations Content Outcome Impression and assessment of the person or situation Plans

5 Document the link of successes and failures to the service plan Documentation should be: Timely Factual Relevant Legible Concise Signed Case Notes, Continued

6 Standardization aids in ensuring effective service delivery Management should provide a written description of case file standards See Guide for USDOL Youth Services suggested requirements for content and sample Case File Checklist Remember – note-taking is essential to managing the process which is a fundamental function of case management

7 Confidentiality Confidentiality restrictions protect people from disclosures that might embarrass them or might lead to discrimination against them. Protecting participants' confidential information may also be necessary for their personal security, as well as their job security.

8 Confidentiality, Continued Young people assured of confidentiality can seek help without fear of disapproval or stigma and can confide with trust, and as a result, benefit more fully from any program. When working with children under the age of 18 however, case managers must be cautious not to promise what they cannot guarantee. It is the responsibility of case managers to be clearly aware of state laws regarding juveniles and mandatory protective service reporting. Programs must, in every case, require that regulations are completely understood and followed by all staff that has access to information.

9 Complying with USDOL and OMB Standards Case managers should develop the following habits: 1. Enter case notes in a timely manner, as close to the actual event as possible 2. Review all files at the end of each month to assure at least one contact was made and recorded with each youth during the month 3. Set aside a specific time each week for record keeping