Guidelines for Social Work Case Management Documentation

SW 611 ~ Guidelines for Social Work Case Management Documentation

What does the NASW Code of Ethics Say?

3.04 Client Records

Social workers should take reasonable steps to ensure that documentation in records is accurate and reflects the services provided.
Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of services provided to clients in the future.
Social workers' documentation should protect clients' privacy to the extent that is possible and appropriate and should include only information that is directly relevant to the delivery of services.
Social workers should store records following the termination of services to ensure reasonable future access. Records should be maintained for the number of years required by state statutes or relevant contracts.

General Professional Guidelines

Consider case management record to be a legal and/or medical document

Documentation follows the agency/organization/state or other governing body protocols and these are followed in the charting. There may be differences in states; know state requirements.

Documentation reflects any significant client, family or ancillary service provider contact

Documentation is sufficiently detailed and organized to enable another social worker to assume work with the client at any time.

Do not leave blanks; write N/A (or not applicable)

Mark any error with a single line and initials – never use correction fluid or tape

Always explain to client documentation process and share with client when possible/appropriate (consider cultural concerns and history in response to "secrecy" of documentation)

Tips and Suggestions

Highlight the client’s strengths, supports and coping mechanisms

Use a professional writing style avoiding jargon, using shorter words with precise meanings, writing short paragraphs focused on a single concept

Do not just report facts as you have been told. Instead, specify where the information came from (client reports/states, client is diagnosed with,)

Remember to report negative (absent) as well as positive (present) observations/information/findings

Each page should have client’s name or identification and include a confidentiality notice

Use Clinician’s Thesaurus or other documentation resource. READ READ READ – read other professional’s progress/case notes.

What to avoid

Never use your own or casual abbreviations (use medical abbreviations)

Do not take shortcuts at the cost of clarity

Do not use generalizations or over-interpretations

SPELL CHECK!...this is your integrity!

Do not use jargon

Do not diagnose if the client does not have a clinical diagnosis (client is depressed, rather say client states that he is having feelings of sadness or depressed mood). OR describe symptoms (client describes seeing hallucinations or is feeling sad on a daily basis)

Do not make recommendations without backing of facts and reason

SW 611 ~ Guidelines for Social Work Case Management Documentation

Initial Intake or Assessment Note

Completed documentation within 48 hours of meeting and supporting documentation should be included within 30 days (i.e proof of income).

Includes introduction of social work case manager/program role and purpose

Includes client rights and responsibilities and grievance mechanism

Client should receive a copy of any work completed together and signed

Includes, but is not limited to:

referral reasons/process

behavioral observations

current living situation

family history

support system

education/employment

financial/insurance

mental health/substance abuse

medications/medical concerns

coping behaviors

legal issues

advance directives

client/family goals

clinical assessment

psychosocial concerns/problem identification

violence/suicidality history

spiritual/cultural factors

Goal Planning/Care Plan

Both short and long term goals/care plan documented

Signature of both client and social work case manager

Priorities and consequences of achievement/non-achievement

Achievements toward or changes in goals documented

Signature (or other documentation of commitment of client and worker)

Progress Notes

Always dated by contact/intervention (If writing late state late entry. If adding information state addendum to note dated XX/XX/XXXX)

Document type or place of contact using:

Home visit, face-to-face, clinic/agency visit, hospital, telephone, mail, collateral contact, community contact, etc.

Document outcome of contact using:

Missed by client, missed by CM, DNKA (did not keep appointment), completed, rescheduled, etc.

Outline reason for contact (client called requesting..., CM conducted scheduled home visit...)
Write in third person and refer to all individuals by title (client, case manager, sister of client, nurse, housing manager)
Write in present tense and identify source for material that is controversial/potentially untrue/client perception. For example, The client describes her parents as severe alcoholics rather than the client’s parents were alcoholics.
Describe client mood, affect, symptoms using client words first, then professional impression
Always end notes with plan (CM will send referral, client will meet with housing CM...)

Sign using credentials (e.g. Sally Social-worker, MSW)

SW 611 ~ Guidelines for Social Work Case Management Documentation

Common Documentation Acronyms, Abbreviations and Statements

	WHAT DOES IT MEAN?	NOTES ON USAGE
/c	With
/s or w/o	Without
ADLs or Activities of Daily Living	Can this person care for him/herself and how well accomplished are the daily tasks?	The client states that these medication side effects do not affect his ADLs.
AMA	Against Medical Advice	Do not use unless the source is a medical professional
CC	Chief Complaint OR Courtesy Copy
Clt or ct	Client
CM or SW	Case Manager or Social worker
Compliance or Adherence	Refers to client’s participation in an intervention or treatment	Client is not adherent to medication or medical care as prescribed
d/c	Discontinued	Usually used with medications
D/ch	Discharged
D/O	disorder
DNKA	Did not keep appointment
DOB/DOD	Date of Birth/Date of Death
Dx	Diagnosis
ETOH	Alcohol
Hx or h/o	History or history of
IDU, intravenous drug use	Use of needles to administer drugs intravenously	Usually used in substance abuse or HIV risk assessment
IEP	Individual education plan	Used in schools
LD	Learning disabled	Use only if backed by assessment
LEP	Limited English Proficiency
MDT	Multidisciplinary team
Medication Regimens	q.d. = everyday o.m. = every morning b.i.d. = twice a day t.i.d. = three times a day q.i.d. = four times a day p.c. = with meals p.r.n. = as needed p.o. = by mouth/oral h.s. = at bedtime i.v. = intravenous
MH	Mental health
MSE	Mental Status Exam/Evaluation
MSM	Men who have Sex with Men	Rather than labeling as gay or homosexual, this term refers to the behavior
NOS	Not Otherwise Specified	Usually used in mental health evaluation or diagnosis
PLWH or PLWA	Person Living With HIV/ AIDS	Usually used in advocacy work
PRN	As needed	Uusually referring to medical care
R/O	Rule Out	Usually referring to DSM-IV diagnosis
Rx or Tx	Treatment or Therapy
SEM/SED	Socially and emotionally maladjusted/disturbed
SMR/PMR	Severely/profoundly mentally retarded
SPMI	Severe and Persistent Mental Illness
SSN	Social Security Number
Sx	Symptom
w/d	Withdrawal

SW 611 ~ Guidelines for Social Work Case Management Documentation

~~~~ SAMPLE PROGRESS NOTE ~~~~~

Bob Smith # 9998989			Confidential Progress Notes
ABC Case Manager – Miracle Worker
Date	Contact	Notes
06/04/03	CC	CM received a call from the intake coordinator who stated that ct was in need of housing and mental health counseling. Intake coordinator set appointment for 06/05/03. CM will contact ct to confirm appointment (ct gave permission for referral and phone contact).----------------------------- --------------------------------------------------------Miracle Worker, BSW
06/05/03	AV	Ct arrived for appointment 45 minutes late. Ct stated that he did not have transportation and had to walk to the agency. Ct is a ~~45 year old~~ Error MW 35 year old Caucasian man. Ct was dressed appropriately for the weather (warm, wore light clothing). Ct was talkative, volunteered feelings/information freely and initiated conversation comfortably. During initial assessment, ct was unclear on the reason for referral and stated that his doctor told him that he needed CM services (Dr. John Smith with XYZ medical center – see referral form). Cm and ct discussed ct-defined problems, formed descriptive problems statements and completed strengths assessment (see assessment form). Ct was uncomfortable with identifying own strengths and supports. CM assisted with education about Strengths Perspective style of Case Management and the role and purpose of the services offered by ABC agency. Ct agreed that he wanted to access services (concurrent with doctor referral). Ct described his history of homelessness since childhood and survival skills used. Ct stated that he prefers not to access homeless shelters and his experiences with such housing services included having belongings stolen and or defaced. Ct indicates that he often lives temporarily with friends and acquaintances that he has met on the street and at shelters. Ct is often expected to pay for this temporary housing through food, alcohol or illegal drugs (marijuana and crack). Ct does not have a regular employment or ~~paycheck from work~~ error MW-- income source but has worked for temporary labor agencies and has done work for cash. Ct stated that when he is lacking on resources he knows how to find income source (usually limited, not reported, and include both legal/illegal work). Ct denied substance abuse concerns, but uses some sort of drug at least 3x per week. Ct stated that substance use does not affect with ADLs however has been denied medical appointments at least 4 times due to being drunk or high. Ct has also been asked to leave formal temporary housing programs due to substance use. Ct feels that this is unfair and was not able to access needed medical care or formal housing programs.

Confidential Client Record Page _1_ of _2_

T= telephone, HV = Home Visit, AV = Agency Visit, M= Mail, CC = Collateral Contact, O _____ = Other

Bob Smith # 9998989			Confidential Progress Notes
ABC Case Manager – Miracle Worker
Date	Contact	Notes
Continued from 06/05/04		Continued --------------------------------------------------------------------------- Ct denies any legal problems related to substance use or other activity. Ct described limited contact to family and asked to avoid any discussion on exploring family relations as informal supports or as a resource for support or housing........................more description of assessment appointment, client needs, deficits in resources, strengths, formal and informal supports and needs................................................................ See Goal Planning worksheet completed by both ct and CM at this appointment. Ct will indicated interest in Shelter Plus Care housing program, but did not want to commit today. ------------------------------ PLAN: Cm and Ct will work on application next appointment. Ct has two medical appointments scheduled and has committed to abstaining from alcohol/drug use before each appointment. Ct and CM strategized that this is more realistic for morning appointments; CM will assist in rescheduling 6/14/04 appointment for a morning time slot. Ct agreed to contact Cm next Tuesday (06/08/04) to discuss eligibility for other support programs offered by ABC including the men’s luncheon support program for homeless men. Ct indicated no other concerns or expectations at this time, but agreed to further conversations about goal planning at next meeting. CM will fax applications completed today including bus pass and lunch pass applications. .......................................................................Miracle Worker, BSW
06/09/04	No Contact	Ct did not contact CM as agreed upon in last meeting (agreed for 06/08/04). CM sent letter to temporary address left by ct. reminding him of medical appointment that was rescheduled on 06/14/04 (see letter copy in chart)---------------------------------------------- Miracle Worker, BSW

Confidential Client Record Page _2_ of _2_

T= telephone, HV = Home Visit, AV = Agency Visit, M= Mail, CC = Collateral Contact, O _____ = Other