<< Click to Display Table of Contents >> Navigation:  Child and Family Services Policy > Section XIII - Case Records > XIII. A. Documentation of Case Management Activity Effective 7/26/06

 

PURPOSE

Narrative entries document purposeful, meaningful contact with critical case members and others. The case note entry describes the caseworker’s performance of basic job functions, including assessment of service needs; development of a specific plan to meet the needs; referral to help the individual obtain needed services; and monitoring and follow-up activities to ensure that the case plan is effectively meeting the identified safety, well being, and permanency needs. Documentation serves several key functions:

 

 

Case recording serves the above-described purposes. It is not for the purpose of documenting how one’s work hours are spent. It is not helpful, for example, to use case narrative entries to document phone contacts repeatedly attempted, or to be a repository for emails and letters received. (If an email is determined by the caseworker to be purposeful contact needing to be included in the narrative log, the email communication, as covered in the Child Welfare Services Email Confidentiality policy, must respect client confidentiality, must be case specific, and must be written with full awareness that it is potentially subject to disclosure. Caseworkers are responsible for discouraging any email communication that violates confidentiality.) Case management contacts are not claimed by the hour, but rather are based upon purposeful contacts made by the caseworker at least one time a month with each critical case member. Documentation of hours spent by the caseworker does not translate into greater reimbursement.

 

These guidelines are meant to help caseworkers frame their narrative contacts in a way which will directly link the purpose of the contact to the services and goals outlined in the Child or Family Plan, as well as to help them document accurately and professionally.

 

These guidelines apply only to open cases and do not apply to documentation requirements for Child Protective Assessments.

 

PROCEDURE:

Case management activities are documented in the Narrative Log in MACWIS. The entries are written in clear, concise language which documents purposeful interaction between the caseworker and the contacted individual. The interaction focuses upon needs identified in the Safety Plan, in the Family Plan, or in the Child Plan and is purposeful in identifying and monitoring services which will address the safety, well-being, and permanency needs of the child.

 

Documentation creates a record of events which are discoverable in court hearings. It is essential that the narration contain an accurate portrayal of facts and statements. The inclusion of erroneous, extraneous, or emotionally reactive statements on the part of the caseworker can be potentially damaging to the Department’s credibility, as well as to the worker’s professional reputation. The caseworker will not use the narrative log as a place in which to vent frustrations and emotions. The narrative log entries will contain professional documentation of observations, discussions, and decisions involving child safety and well being.

 

Time Frames for Documentation:

Documentation of contacts will be made within ten work days of their occurrence, in order to decrease the risk of inaccurate recordings due to limitations of memory. By promptly documenting succinct factual information, one is capturing the unfolding "story" in the life of the child and family, while simultaneously accurately reporting events needed for funding purposes and for providing a discoverable record for court purposes.

 

Amending Documentation:

The narrative log may be amended at the request of a supervisor, if the entry was either inaccurate when made or has some significant grammatical or reporting errors. The case worker should not change the original entry, but rather add to the original entry with a notation that the entry has been amended on the date and time of the amendment entry, followed by the amendment information.

 

In exceptional circumstances, the Director, or designee, of Child Welfare Services can approve the removal or modification of a narrative entry, in consultation with the Division Chief, or designee, of the Child Protection Division in the Office of the Attorney General.

 

Format and Tone of Documentation:

Discussion of team decisions will be portrayed professionally and accurately. An example of a professional and accurate description is:

 

"My supervisor and I discussed the information thoroughly, and determined not to proceed with a request for a PPO at this time. We decided to proceed as follows…."

 

Information in the narrative log will contain specific elements relating to meaningful monthly contact with children and parents, as well as meaningful contact with foster parents and collateral contacts.  These key components are:

 

 

The purpose must directly relate to the reason that the family needed Child Protective Services due to the family/environment creating a serious threat to the child’s safety or welfare, or due to the parent or caregiver failing to meet the child’s basic need for emotional and/or physical care and protection. Documentation of caseworker activities will relate to continued assessing of strengths and needs identified in the Safety/Family Plan, and monitoring the effectiveness of services in adequately meeting the needs.

 

Similarly, for a child in the custody of the Department of Health and Human Services, the purpose of the contact with the child or with his family must directly relate to the reason(s) that the child came into care and to the referral for and/or monitoring of services being provided to meet the needs identified in either the Family Plan or in the Child Plan.

 

Documentation of caseworker activities will include efforts made to meet the child’s need for permanency. Purposeful contacts with the child and with identified family and community contacts, as well as recruitment efforts, will be documented to demonstrate the caseworker’s efforts to help the child achieve permanency.

 

 

 

 

In writing a narrative log entry, the caseworker will use words which clearly identify that the contact was a professional case management activity. By using words such as advocate, arrange, coordinate, assess, explore, facilitate, negotiate, refer, monitor, and schedule, it will be apparent that the contact was a legitimate case management service.

 

The caseworker will write the narrative using the first person "I" perspective, rather than using the third- person "the caseworker" perspective. One shall also identify for the reader the role that the person contacted has in relationship to the critical case members. Finally, the caseworker will identify the full name of the person or agency. If one wants to use an acronym in a case note, one must first fully name the agency or entity, followed by the acronym in parentheses, and then employ the acronym in the remainder of that narrative entry. Following these principals will result in natural and understandable entries. An example follows:

 

"I spoke with Andrea Smith, Jeffrey’s foster mother, about the transportation that I have scheduled with Kennebec Valley Community Action Program (KVCAP) for Jeffrey to be transported to his therapy appointment each week. KVCAP will pick up Jeffrey at school at the end of the school day every Thursday; will take him to his therapy session; and will transport him back to the foster home following his session."

 

Case Narrative Documentation for Medicaid Targeted Case Management:

Medicaid –reimbursable activities must be identified as Case Management contacts. These Medicaid –reimbursable activities fall into one of the following categories:

 

 

Again, case management contacts are not claimed by the hour, but rather are based upon purposeful contacts made by the caseworker at least one time a month with each critical case member. Documentation of hours spent by the caseworker does not translate into greater reimbursement.

                 

EXAMPLES OF NARRATIVE LOG CASE MANAGEMENT ENTRIES:

Documentation of a situation in which the caseworker is meeting with the child during a monthly contact, has identified a continuing need relating to the Child Plan, and is continuing to monitor services to address the need:

The purpose of this visit with ten-year-old John Blake at his foster home was to assess his safety and well-being, as well as to monitor the effectiveness of the services in place.

Summary of contact: During this visit, I observed that John is continuing to hoard food in his room. I asked John to tell me about mealtimes in his foster home, and he described normal family meals, with the provision of second helpings, if he chooses them. When I asked him about all the food he brings to his room, he told me that he doesn’t want to be hungry. John came into care three months ago as a result of a finding of jeopardy due to high severity neglect. At the last Family Team Meeting, the team discussed his hoarding behavior, concluding that as John became confident in knowing that food and nurturance would be provided, the behavior would decrease. As an identified service in his Child Plan, John receives mental health therapy services to address past trauma issues and to help him adjust to his changed circumstances.

Outcome/Next Steps: Patty Smith, foster mother, agreed to contact the therapist to seek advice on any strategies that may help reassure John that he will always receive sufficient amounts of food and nurturing care in her home. I will meet with John again next month to talk with him about his experiences and feelings, and will continue to monitor the effectiveness of services in helping him feel safe.

 

Documentation of a case management service involving monitoring effectiveness of services in helping a birth parent make progress toward reunification:

The purpose of my meeting with Mary Jones at her home was to monitor whether or not the services in place are adequately addressing reunification needs. One of the needs noted in the Family Plan was Mary’s need to become compliant with taking her prescribed medications. In the past, Mary’s non-compliance with taking the medications for her condition of bi-polar disorder resulted in dangerous behaviors which caused her children to be in circumstances of jeopardy.

Summary of contact:  She talked with me about the strategies that she is using to help her remember to take her medications.  She described her past behavior as often deliberately "forgetting" to take her medication, and instead drinking with her friends. Mary described how, with the help of her therapist and her substance abuse support group, she is no longer "self-medicating" with alcohol, and is instead conscientiously taking her medications, as prescribed.

Outcome/Next Steps: In the following month, I will supervise a visit between Mary and her children, in order to assess progress in the quality of their interaction, and to recommend whether or not any additional facilitated visitation services would be beneficial to help repair the parent –child relationship. Prior to the visit, Mary and I will discuss and decide upon a community location site for her visit with her children.

 

Documentation of a case management service provided to a parent who has been determined to be in need of Child Protective Services. The caseworker is helping arrange services to meet safety needs identified in the Family Plan.

The purpose of my phone contact with Amanda Brown was to discuss the day care provider choices available to her. The need for Amanda to participate in parenting education classes was identified in the Family Plan. In order to participate in these classes, Amanda will need help with childcare for her child.

Summary of contact: Amanda has agreed to place her daughter Stacy in day care two days a week, which will then make it possible for Amanda to attend parenting classes. Amanda would like to visit the daycares before making a decision. I provided her with the contact names and phone numbers of the daycare resources available to her.

Outcome/Next Steps: Amanda will call by next week to let me know which of the two daycares she chooses, and I will then refer Stacy to the daycare of her choice. I will continue to measure the effectiveness of services in addressing the issues of abuse and neglect which led to the Child Protection Assessment Decision that this is a family in need of Child Protective Services.