Case Recording Styles

Rehabilitation 413W: Case Management and Case

Recording

Learning Objectives

1. To present and clarify different models of documentation of the case-management activities of a rehabilitation professional in the rehabilitative treatment of a client.

2. To increase awareness in students of the appropriate information to include in a client’s record and to increase knowledge regarding the purposes of effective documentation.

Case Record

Definition

A set of documents usually placed in a file folder about a particular person and his or her relevant contacts, interactions, and/ or needs.

Case Record: Purpose

Documentation

Service continuity

Reimbursement

Quality control

Statistics

Treatment planning

Litigation, protection, and prevention

Therapeutic charting of progress

Items in the Case Record

Phone screening of the initial call for services or from the referring agency

Questionnaires and historical data sheets

Medical reports

Psychiatric and psychosocial reports

Consent forms and client related correspondence

Case consultation notes

Items in Case Record Continued

Referral information Progress notes (also called case notes)*****Record of services providedGoals and objectives and treatment plansDischarge summaryAftercare plansFollow up informationFinancial records

Lois’ Rules of Thumb

Would I feel o.k. about my client reading what I plan to write in this case record?

Will I feel comfortable explaining my justification for what I have written if my client sees the record (his or her right) and challenges my words (another right)?

Never IncludeIntimate or personal details that have no bearing on the client’s needs or situation

Gossip

Venting of own frustration or other feelings

Incriminating information to you or the agency

Inappropriate entries such as your own personal view of religion or politics etc.

Case Notes: Basic Principles

Assist the reader Be accurate and objectiveSimple and direct styleUse basic English Describe what happened Avoid uncommon abbreviationsRecord in a timely mannerRelevant significant information ONLY

Case Note Styles

Summary Style

POR=Problem-Oriented Recording

DAP=Data-Assessment-Plan

SOAP*=Subjective-Objective-Assessment-Plan

APIE=Assessment-Plan-Intervention-Evaluation

STIPS=Signs and Symptoms-Topics of Discussion-Interventions-Progress & Plan-Special Issues

*Sometimes literature has referred to the S in SOAP as Summary and the A in SOAP as Analysis

Summary Style Case Note

Interview content

Client disclosures

Omit irrelevant details

Describe details you as a professional deem important

Document the outcome not the steps

Summary Style Case Note ExampleDate: Wed. 3/3/2004 10:00 AM Session: 5Client: Elizabeth James Client # 234Purpose: Discuss results of vocational evaluation

Elizabeth and I met today for 45 minutes to review the results of her vocational evaluation. (See previous note for results of evaluation). Elizabeth was early for our session and she said that she was anxious to find out the results of the test. We spent a few minutes initially discussing how she felt about the evaluation experience and what she hopes to learn from the results. She stated that she wants to learn “what kinds of jobs would be the most appropriate for me now, given my limitations.” After I showed her how to interpret the GTAB scores and what the different categories meant, I then showed her how to use the DOT and OOH and then went into the library for 30 minutes to review this information. She said she had to leave for another meeting so we scheduled another appointment for Wed. 3/10/2004 at 10:00 AM.

Problem-Oriented Recording

Identify problem areasAssess those areasState what action is needed about each problem

Using this type of case note can be an advantage in interdisciplinary settings when many different professionals are working on the same problem or with the same individual

Problem Oriented Recording ExampleClient’s Name: Jane Brown Client’s #: 823Date: Tuesday 3/16/2004 @ 11:00 AM

Problem 1: Client feels uncomfortable with leg amputationMD: Examined on 3/10/2004 and found healing process to be going well. A prosthesis appointment set for 3/22/2004.Prosthetist: Due to see client on 3/22/04 but has also sent client some questionnaires to fill out. She had identified that she is avoiding doing so.RC: Noticed that the client appears to be having difficulty adjusting emotionally and psychologically to the disability that occurred as a result of a serious car accident. Will refer to the rehabilitation psychologist for an assessment on client’s mood and adjustment process in order to gain disturbance and agrees that a psychological consult is needed information to assist client in achieving healthy adjustment.SW: Indicated that the client refused to go to the lunchroom and to socialize with other patients. She also suspects a mood issue.

SOAP Case NotesS=Subjective Information from the client

His or her feelings

Concerns, issues, situations, problems

His or her goals and plans

Pertinent comments by the client’s family members or other people like probation officers or other professionals as disclosed by the client

SOAP Continued

O=Objective Data: Factual information that can be seen, heard, smelled, counted or measured

Rehabilitation professional’s observations of physical, interpersonal, affective or psychological issues apparent in the meeting

Key words: seemed, appeared, as evidenced by

SOAP Continued

A=Assessment: a summarization of the rehabilitation professional’s ‘clinical thinking’

regarding the client’s issues or problems during this particular session

Issues that need to be further addressed

Unhealthy patterns that need to be challenged

Level of cooperation/insight/motivation

Effectiveness of treatment strategies

Client progress and setbacks

SOAP Continued

P=Plan: Identification of the next step that the rehabilitation professional plans to

take regarding the client

Identify the plan for the next meeting

Document the date and time of the nest session

Identify any other referral activity that the professional will pursue

Identify assigned homework

SOAP ExampleRehab 413W Counseling Center

Progress NoteClient Name: Ron Smith Client #: 123Date: Mon. 3/22/2004 @ 2:00 PM

S- The client came readily to the meeting room and indicated that he had a great deal to talk about today. He identified that since our last meeting he had followed through on both his homework assignment (Barriers to Success) and had attended a support group meeting. He described his feelings as anxious and sad about both the homework and the meeting. He indicated that the more the other members of the support group discussed their disability issues the more ‘down’ he became. The client indicated that he was so upset that he just ‘passed’ when it was his time to speak at the meeting.

SOAP Example Continued

O- As the client shared his feelings and thoughts his eyes began to tear up although no tears fell. Affect looked sad and discouraged although he denied that this sadness was about anything but having to attend this support group for homework. The client was also more disheveled in today’s session then in past meetings as evidenced by rough uncombed hair and unshaven face.

SOAP Example Continued

A- The client appeared to be more depressed today then in past meetings. The fact that he ‘passed’ when given the chance to discuss in the support group causes concern for me that the client is avoiding or repressing sad or possible other feelings about his disability issues. When asked directly if he was feeling self destructive in any way, he denied this. He also denied any difficulties sleeping or eating.

SOAP Example Continued

P- The client was asked to do the next few pages of the Barriers to Success workbook and the plan is to discuss his responses to this week’s pages and next week’s as well. I will reassess depressive symptoms again next week and will possibly pursue a referral to the psychiatrist if the depression seems unchanged or worse. Our next appointment is Monday, 4/5/2004 @ 3:00 PM

Provider’s Signature:_____________________

DAP Case NotesD=Data: In this style the subjective information and the objective information of the SOAP style is combined in one section.

A=Assessment: This is the same information that is included in the A part of the SOAP case note

P=Plan: This is the same information that is included in the P part of the SOAP case note.

DAP ExampleRehab 413W Counseling Center

Progress Note

Client Name: Jane Brown Client #: 345

Date: Mon. 3/22/2004 @ 4:00 PM

D-The client came approximately 10 minutes late to the appointment and indicated that this was due to difficulties getting in and out of her vehicle. She expressed much frustration about the way her artificial limb seems to be slowing down her lifestyle and how angry she feels that she is unable to so other physically rewarding activities (skiing, jogging) that she enjoyed in her active lifestyle in the past. In other matters, she reports that work and family relationships are going well and that functioning in the home taking care of her children and housework are fine. She became quiet and looked at the floor when I asked her how she and her husband were managing in their relationship. She took a deep breath and said, “We’re doing fine also.”

DAP Case Note Example Continued

A- Although she indicated that much in her life was fine her affect was sad and anxious especially when discussing her relationship with her husband since her accident. I mentioned this incongruity and although she minimized her feelings she did acknowledge that they have been arguing a great deal of late and she has felt worried that her marriage would not triumph over this most recent obstacle (Car accident). I attempted to approach the subject of her child’s death at the time of the accident but she changed the subject rapidly and refused to process any information about this aspect of the tragedy. I wonder if some of the strain between her and her husband has to do with this mutual loss. I asked her if her husband was willing to come in for a joint session and she indicated she would ask him.

DAP Case Note Continued

P- The plan is to continue to see this individual weekly in order to support her adjustment post accident recovery. I will also attempt to set up a couples session so that I can talk with both the client and her husband about possible marital therapy with a specialist in rehabilitation issues. In the next individual session with the client I will check out her frustration level regarding the slower pace she feels she now has to take and I will talk with her about a referral back to the technical assistance specialist to see if some adjustments need to be made regarding her limb and other accommodations. Our next appointment is set for Monday 3/29/2004 @ 4:00 PM.

Provider’s Signature:___________________________

Ending Comments about Case Notes and Paper

Work in General

First line of defense

Other professionals depend on your notes

Good documentation >>better understanding of client needs

How to Avoid Drowning in the Paperwork

Awareness about the importance

Find a routine

Formally schedule time

Eliminate unnecessary paperwork