Case NotesCase Notes

DATE anything you write

QUOTE exactly as stated

Recognize PERTINENT information

Write in SPECIFIC, OBSERVABLE and MEASURABLE terms

If your OPINION, say so

• 55

Case Note Exercise

ObservaObservationtion

Bill Bill came in came in looking looking a mess a mess & &

stressed stressed outout

• 55JanuaryJanuary

44 3January

Case Note Exercise

ObservaObservationtion

Mark Mark was was angry at angry at the the

world!world!

• 55JanuaryJanuary

55 4January

Case Note Exercise

ObservaObservationtion

Olivia Olivia was late was late again!again!

• 55JanuaryJanuary

77 6January

Case Note Exercise

ObservaObservationtion

John John said he said he felt like felt like killing killing someonesomeone!!

• 55JanuaryJanuary

55 4January

Case Note Exercise

ObservaObserva

tiontionMarsha Marsha was was notnot cooperat

cooperatinging

Individualized Development PlanIndividualized Development Plan

COMPETENCY:Be able to assist clients with the

creation and implementation of Individualized Development Plan

IDP Process

Essential Elements-IDP’s Essential Elements-IDP’s

• Identifying information• Summary of education and

training• Employability issues• Current Services being

received from other agencies

Elements of IDP’s (continued) Elements of IDP’s (continued)

• Identified goals: – Long term– Short term– Steps to achieve each short term

goal– Person responsible– Follow-up dateSignature/date

Reviewing The IDP• Summary of the assessment• State specific goals• State who is responsible• Dates for each step accomplished• Client’s & case manager’s signatures• Client should be given a copy• Reviewed and updated regularly• Can notes be deciphered

Case Management Follow-Up on Referrals

Confirm the client attended the appointment.

Confirm the client attended the appointment.

Identify what transpired at the appointment through the eyes of both parties.

Identify what transpired at the appointment through the eyes of both parties.Determine what the

client’s next steps are. Is the case manager’s support needed, and whether a modification of the IDP is required.

Determine what the client’s next steps are. Is the case manager’s support needed, and whether a modification of the IDP is required.

Take corrective measures (such as rescheduling) if the client did not attend the appointment as planned.

Take corrective measures (such as rescheduling) if the client did not attend the appointment as planned.

Track and Monitor the IDPTrack and Monitor the IDP

Assess continuing appropriateness of plan

Conduct follow-up interviews with client, service providers, and employersAssess and analyze client’s progressProvide assistance and support toward completion of client’s IDP

Assess Continuing Appropriateness

• Areas unexplored• Were referrals for support adequate • Lack of motivation• Long term goals too much• Are they really the client’s goals