4050
Background
The primary mission of the social work profession is to enhance human well-being and to help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty (NASW, 2008). A case manager is a professional person designated to assume primary responsibility for accessing the needs of a participant, arranging and coordinating the delivery of essential goods and services provided by other resources, and working directly with the participant to ensure that the goods and services are provided in a timely manner.
Recording case notes can support this mission in the following ways:
- Assessment Summary
- Documented deficiencies and barriers recorded in case notes should be linked directly to services and activities provided by the agency
- Case Management Guide
- Case notes allows tracking and reporting of client contact and progress
- Keeping well documented notes will allow you to capture any newly emerging barriers
- This will help revise the client's action plan as they go
- Accountability
- HMIS is considered the "system of record", and is considered the authoritative source for homelessness data in Orange County
- Recording everything in one place allows for internal oversight and makes monitoring and auditing easier on the agencies
- Information Sharing
- In-house: Sharing of important data and action plans are critical to the success of clients in programs
- External: Sharing case notes will optimize referral relationships with outside partner agencies and allow for a better action plan for the client
In order to more effectively coordinate a client's care as it relates to housing, the Orange County CoC would like to be able to share notes related to housing in HMIS. However, there is also a need for agencies to enter case notes that are only viewable to users at that agency. This article covers the difference between Case Notes and Housing Notes, and how to enter both correctly into HMIS to ensure the correct information is shared or kept private. When entering Case Notes or Housing Notes, remember that the client has the right to review anything in their client record, including Case Notes and Housing Notes.
Case Notes
Case Notes are only visible to the agency that created the note. Case Notes should be used to track information regarding the client's enrollment that should not be shared with the CoC. Examples of information that should be entered as case notes include incident reports and mental health concerns. Case Notes should be entered on the Notes tab of the client's enrollment. Please review the Creating Client Notes and Public Notes article for more instruction on entering case notes in HMIS.
Best Practices for entering Case Notes
- Case notes should be entered the same day that the incident or session related to the case note occurred, or the next day if it is not possible to enter them on the same day. Recording the information as soon as possible makes it so that information is more accurately collected.
- It is important that case note utilize as many facts as possible. Record what was observed or heard and by whom, as well as any historical information (verified by available information)
- If recording inferences or assumptions, it is necessary to identify these entries as such. Phrases such as "appeared to me" or "seems to be" should be used, then explain why the inference or assumption is being made.
- Case notes should avoid diagnosing, jargon, or stereotypes and prejudices.
- Case notes should avoid using emotionally charged words. Some examples of emotionally charged words include abnormal, dangerous, delusional, disturbed, hysterical, immature, impulsive, threatening, and uncooperative.
- Complete sentences do not need to be used as long as the meaning or intent of the statement is clear and intact
- Case notes should only contain relevant information, meaning that it only contains important and significant information that relates directly to the client's well-being.
Examples of Case Notes that do not follow Best Practices
- "I drove over to the workshop to see Kris, went into the building and saw her talking to a friend. I walked up to her and I needed to talk with her about her SSI check."
- "Derek was acting out."
- "Mrs. Jacobs seems very depressed."
Examples of Case Notes that follow Best Practices
- "I talked with Kris about her SSI check."
- "Derek skipped school and was caught shoplifting."
- "Mrs. Jacobs stated 'Of course I'm depressed. Wouldn't you be if you were in my situation?'"
Housing Notes
Housing Notes should be used for information related to housing the client. These notes will be shared with the CoC in order to streamline the housing process for the client and to coordinated care among multiple agencies. Housing Notes should be entered under the Provide Services tab of the client's enrollment. Please review the Adding Services article for more instruction on how to enter services in HMIS.
Format for Entering Housing Notes
Housing Notes should follow the PIRP format: Purpose, Intervention, Response, Plan
Purpose: Identify the purpose of the session
- When documenting the purpose be clear and descriptive when detailing the client's current situation(s), condition(s), and assessment of client and/or reason presented during the session.
- Question to answer:
- Why is this session necessary?
Intervention: The intervention you provided in the session
- When documenting the intervention use descriptive sentences about your interventions (i.e. what you did). Identify the skills used to cope, adapt, respond, or problem solve. Reinforce new behavior and strengths. Identify specific skills that are taught, modeled, or practiced.
- Question to answer:
- What did you do to assist the client?
Response: This is the response of the client to your intervention.
- When documenting the response use descriptive sentences about the client's response to the staff's intervention. Describe the response to the intervention in behavioral terms and include the client's progress or lack of progress. The response may also include a description of other significant changes in client status.
- Questions to answer:
- What was the client's response to intervention?
- Explain the reasons for lack of improvement.
- Include outcome measures in documentation, as appropriate.
- Progress towards goals/objectives.
Plan: These are the next steps determined by you and the client to achieve housing goals.
- When you document the plan include the referrals to be made, follow-up items, homework assignments, etc.
- Question to answer:
- What action items were determined to help move the client towards permanent housing?
Example of PIRP Format
(Purpose): Client is currently receiving rental assistance (Rapid Re-Housing). Client needs a means to continue making rental payments when the Rapid Re-housing assistance ends.
(Intervention): Identified benefits that the client may be eligible for. Referred client to resource to assist with resume building.
(Response): Client agrees that she needs both benefits and income in order to maintain rental payments in the future.
(Plan): Client will apply for the benefits identified by next Friday. She will also work on her resume and bring a draft to our meeting in two weeks.
Reviewing Housing Notes entered by Other Agencies
Housing Notes can be reviewed by any agency participating in HMIS. To review a client's Housing Notes, follow the steps below.
- Navigate to the History page under the client record.
- Click on the View dropdown to expand the Advanced Search Options.
- Enter 'housing notes' into the Search field, and click on Search.
- The client's History page will show any Housing Notes entered on the client's behalf. The name of the agency that entered the Housing Note is below the Service Name.
- Hovering over the double square icon lists the Project the Housing Note is associated with, as well as the Project Start and End Dates.
- Hovering over the dialogue square will show the contents of the Housing Note.
