SPECIAL TOPICS MODULE
CASE
MANAGEMENT:
CASE NOTES
Special Topic Module: Case Notes
OBJECTIVES
The objectives of this module are to:
I. Explain the function of
case notes,
II. Demonstrate the usage
of case notes, and
III. Present guidelines
for writing effective
case notes.
Special Topic Module: Case Notes
INTRODUCTION
A unique service provided by the
DVOP/LVER Program is effective
case management. As one of the most
important aspects of your job, it
requires consistent, accurate and
complete documentation. That is why
good case notes are so important.
Special Topic Module: Case Notes
INTRODUCTION cont…
Required case documentation can
vary from state to state, but the case
notes you take are a continuous record
of your interaction with the client.
As such, they are an indispensable
tool that no DVOP or LVER should
do without.
Special Topic Module: Case Notes
I. Functions of Case Notes
1. Documentation of Services
2. Clarification and Planning
3. Tracking Progress
4. IDP Adjustment
5. Job Accountability
Special Topic Module: Case Notes
I. Functions of Case Notes:
1. Documentation of Service
Case notes provide a step-by-step
outline in case…
 You leave and someone takes over the
case,
 Your supervisor needs access to the
information, or
 Your records are subpoenaed by the court
system.
Special Topic Module: Case Notes
I. Functions of Case Notes:
2. Clarification and Planning
By encouraging you to put your
observations about the client into
concise words, the note taking
process helps you clarify what
needs to be accomplished by both
you and your client.
Special Topic Module: Case Notes
I. Functions of Case Notes:
3. Tracking Progress
By tracking the progress of your
client with case notes, you will be
better equip to recognize behavior
patterns or analyze employment
barriers the client needs to
overcome to be successful.
Special Topic Module: Case Notes
I. Functions of Case Notes:
4. IDP Adjustment
In addition to tracking your
client’s progress, case notes help
you become more familiar with
your client’s needs, pace and
attitudes. This, in turn, will
indicate if adjustments need to be
made to the client’s Individual
Development Plan (IDP).
Special Topic Module: Case Notes
I. Functions of Case Notes:
5. Job Accountability
 Case notes are the most accurate,
complete and personalized
record of your work with the
client, and
 A record of your client’s
progress and willingness to work
towards employment and/or
rehabilitation.
Special Topic Module: Case Notes
II. Using Case Notes
1. Informing your client
2. Confidentiality
3. Accuracy
4. Brevity and
bShorthand
Special Topic Module: Case Notes
II. Using Case Notes:
1. Informing Your Client
• It is important to inform your client
why you are taking notes and how
they will be used.
• Remember, the key to effective case
management is to establish a
partnership with the client. You do
not want to appear to be keeping
secrets.
Special Topic Module: Case Notes
II. Using Case Notes:
1. Informing Your Client cont…
• Share your notes with the client.
o Your client should feel comfortable
enough to share personal
information with you.
o Sharing instills a sense of control to
the client that is vital to his or her
progress and independence.
o Working with the client helps you
keep your notes honest and accurate.
Special Topic Module: Case Notes
II. Using Case Notes:
2. Confidentiality
• Do not promise that your notes
will be seen only by yourself and
your client.
• However, you should make every
effort to keep the information
secured in a confidential file and
under lock and key.
Special Topic Module: Case Notes
II. Using Case Notes:
3. Accuracy
• Accuracy is crucial when writing
case notes. Remember, these
documents can be subpoenaed.
o Do not leave your statements open
to interpretation. Be specific.
o Do not make comments that you
would not want the client to read.
o Do not make diagnoses or offer
conclusions that you are not qualified
to make.
Special Topic Module: Case Notes
II. Using Case Notes:
4. Brevity and Shorthand
• Your note taking should be brief and
not too time consuming.
• Using shorthand in your notes is
fine as long as you include a key in
each file. Otherwise, your notes are
useless to others.
Special Topic Module: Case Notes
III. Case Note Guidelines
G1. Date & Initial Everything
G2. Using Quotations
G3. Pertinent Information
G4. Specific, Observable
and Measurable Terms
G5. Your Opinions
G6. Current Status
Special Topic Module: Case Notes
III. Case Note Guidelines:
G1. Date & Initial Everything
 All entries, even failed attempts to
contact the client, should include
date, time and initials.
 Keep in chronological order with
most recent on top to maintain an
organized and logical format.
 Explain gaps in time.
 Look for patterns that may develop.
Special Topic Module: Case Notes
III. Case Note Guidelines:
G1. Date & Initial Everything
cont…
Peterson, Joel
Special Topic Module: Case Notes
III. Case Note Guidelines:
G2. Using Quotations
 It is critical to use quotes when the
client offers shocking, surprising or
baffling information.
 Quotes must be kept in context.
 Quotes give personality to the client
and credibility to the note taker.
Special Topic Module: Case Notes
III. Case Note Guidelines:
G2. Using Quotations cont…
 Quote the client when he or she
says something out of character or
that would impact job placement.
“I felt like
strangling
her!”
“I don’t
really want
to work.”
“My husband
left me and my
children!”
Special Topic Module: Case Notes
III. Case Note Guidelines:
G3. Pertinent Information
 Focus on the client’s ability to
obtain their goals.
 Any information which could
impact their goals should also be
considered pertinent.
Special Topic Module: Case Notes
III. Case Note Guidelines:
G4. Specific, Observable and
Measurable Terms
 The most crucial skill of note taking is
speaking in specific, observable and
measurable terms. You don’t want to
leave your comments open to
interpretation.
 Don’t judge your client or make
unprofessional or unsubstantiated
comments about their lifestyle,
appearance, personality or behavior.
Special Topic Module: Case Notes
III. Case Note Guidelines:
G4. Specific, Observable and
Measurable Terms cont…
Non-Specific
More Specific
drinking problem.”
“Both times we met, he
smelled of alcohol and
stumbled when he walked.”
“She was late again
today.”
“She arrived 15 minutes late,
saying she had car trouble.”
“He was agitated and
uncooperative.”
“He shouted and jumped out
of his seat several times. He
refused to answer questions.”
“He obviously has a
Special Topic Module: Case Notes
III. Case Note Guidelines:
G5. Your Opinions
 If something is in your opinion,
make sure you say so.
 Opinions should be used
sparingly or not at all.
 If you state your opinion, have
some documented evidence to
back it up.
Special Topic Module: Case Notes
III. Case Note Guidelines:
G5. Your Opinions cont…
Mr. Peters, in my
opinion, is not yet
ready to look for a job.
He has several barriers
(see IDP) that he needs
to overcome before he
is job ready.
Special Topic Module: Case Notes
III. Case Note Guidelines:
G6. Current Status
 Before initialing your case note
entry, include information regarding
your next contact. For example:
 Date and time of next
appointment or phone call
 A note to remind yourself what you
or the client plan to accomplish
before the next meeting.
Special Topic Module: Case Notes
Case Notes for Frank Hogkins
4/4/00 Frank has made great progress the
3:00 pm past two weeks. After completing his
VR&E training, he attended our job
search workshop and has already
been interviewed for a computer
programmer position. However, when
asked how the interview went,
Frank said, “He asked me some
questions that I just didn’t know how
to answer.” I have scheduled Frank
to come in on Monday to watch the
Ultimate Job Search: Interviewing
with Confidence video.
LB
Special Topic Module: Case Notes
Case Notes for Frank Hogkins
4/4/00 Frank has made great progress the
3:00 pm past two weeks. After completing his
G
1
G2
G6
VR&E training, he attended our job
search workshop and has already
been interviewed for a computer
programmer position. However, when
asked how the interview went,
Frank said, “He asked me some
questions that I just didn’t know how
to answer.” I have scheduled Frank
to come in on Monday to watch the
Ultimate Job Search: Interviewing
with Confidence video.
G1
LB
Special Topic Module: Case Notes
Case Notes
Joe Bishop
9/1/00
3:00 pm
-30% Disabled (shoulder injury)
-Laid off from the mill
-Worked 7 years grain elevator op. Has wife and two kids
Accommodation- no heavy lifting
-In my opinion, job ready
-Referred to machine op. position at
the dam. Interviews tomorrow.
Next appt. 9/5/00 2 pm
ZK
Special Topic Module: Case Notes
Case Notes
Joe Bishop
G4
G3
G5
G1
9/1/00
3:00 pm
-30% Disabled (shoulder injury)
-Laid off from the mill
-Worked 7 years grain elevator op. Has wife and two kids
Accommodation- no heavy lifting
-In my opinion, job ready
-Referred to machine op. position at
the dam. Interviews tomorrow.
G6
Next appt. 9/5/00 2 pm
ZK
G1
Special Topic Module: Case Notes
Laura Bing ~ Case Notes
5/5/00 Laura is a 40 year old homeless woman
1-1:30 who lost her last job in the food industry
after suffering a mild stroke. She has lost
partial use of her left arm. She said,“It is
hard for me to lift things and I tire easily.”
I had her apply for unemployment and
have arranged for her to meet an
occupational therapist at the VAMC next
Tuesday. I also referred her to the parish
homeless shelter until a spot becomes
available in the VA facility and provided
her with some bus passes to get around on.
Look into disability options before next
meeting on 5/10/00 at 4 pm.
RJ
Special Topic Module: Case Notes
G
6
Laura Bing ~ Case Notes
5/5/00 Laura is a 40 year old homeless woman
G3/4
1-1:30 who lost her last job in the food industry
G3/4
G6
after suffering a mild stroke. She has lost
partial use of her left arm. She said,“It is
G2
hard for me to lift things and I tire easily.”
I had her apply for unemployment and
have arranged for her to meet an
occupational therapist at the VAMC next
Tuesday. I also referred her to the parish
homeless shelter until a spot becomes
available in the VA facility and provided
her with some bus passes to get around on.
Look into disability options before next
meeting on 5/10/00 at 4 pm.
RJ G1