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 Plans Focus on just the facts

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 Provide a brief overview of the youth, goals, strengths and barriers for first case note entry Provide updates at least monthly Remember – note-taking is essential to managing the process which is a fundamental function of case management

First Case Note Background Age, Grade, Living Situation School needs Employment needs Strengths and challenges First steps 7

Example: Kimberly Met with Kimberly. She’s 17 years old and is currently working towards a diploma. She has 18 credits and needs 8 more to graduate. Kimberly lives with her mom and has a 6 month old baby. She states her grandmother provides childcare and will continue to do so while she attends school. Kimberly receives TANF assistance and DHS provides a bus pass. She is not currently interested in working, but would like info on parenting support groups. She is interested in a career as a nurse. Provided info about upcoming nursing event at Providence. Set goal to gain credits toward graduation. Made appointment for 3/8/10 to discuss credit recovery. 8

Example: Kimberly 9

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Example: Kimberly 11

Example: Kimberly 12

13 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.

14 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.

15 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

Case Note: Kimberly Date: 11/28/06 Kimberly called today to give an update. She has been attending GED classes regularly. She says she likes the instructor and is doing well. She also reported that she has completed the job skills/job search course and is looking for employment. She needs documentation for TANF so that she can get childcare. She has been looking at day care centers that she can get to easily. We made an appointment for next Friday to make further plans. 16

Case Note: Clarence 11/28/09 Clarence came to the agency today and we explored job opportunities. He is interested in almost anything as long as the pay is good. He says that he and his mother are arguing more frequently and he has to find work soon. Clarence is cooperative when talking with staff here but often does not follow through on suggestions. Hopefully, he will keep the promises he made today. We will be meeting again next week. 17