Effective Strategies for Writing and Managing Case Notes in Veterans Programs
Enhance your skills in documenting case notes for veterans by understanding the purpose, importance, and guidelines. Learn how to address delicate topics with sensitivity while ensuring clear, concise, and professional notes. Improve your documentation quality with practical tips and examples provided in the training program.
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Case Notes Made Easy Veterans Program Training
CASE NOTE OVERVIEW Purpose. Who, What, When, Where, Why. Writing Case Notes. General rules. Documenting delicate topic tips. Quality control. Case Notes sample quiz.
WHY ARE CASE NOTES IMPORTANT? Provide a chronological record of the delivery of services and support to veterans and eligible persons. Provide the necessary documentation to support claims to federal funding sources. Provide a single place for supervisors and colleagues, state and federal auditors and others with appropriate clearance to read about recent case activity. Other examples.
WHO! WHAT! WHEN! WHERE! WHY! Who did you speak with? Person you had contact with. What was the substance of the interaction? Meeting content and process, situation or problem, etc. When is the customer supposed to complete their activity/task? Follow-up and know what you are following up on. Where was the contact made? Telephone, in person, email, office, home, outreach, etc. Why did the contact occur? Why is the veteran being served?
WRITING CASE NOTES Clear and concise (if it is in conjunction with the assessment): The Significant Barrier to Employment (SBE) should be easy to identify. Recommend clearly stating the veteran s SBE in the opening line (if it is an assessment 102/103). Be professional: Avoid abbreviations, acronyms, jargon, street talk, stereotypes, etc. Don t be cryptic: Avoid writing so you are the only one who understands what transpired. Readable (acceptable grammar): Proofread, use spell check, be accurate.
GENERAL RULES FOR CASE NOTES Describe behaviors. Record statements made by customer. Record your observations. Substantiate conclusions and judgments: only the facts. Link services to documented deficiencies. Update Case Note frequently and promptly. Anytime there is interaction with customer (phone call, in person, etc.). Be written while the information is fresh in your mind. Keep it relevant to the Individual Employment Plan (IEP).
DELICATE TOPICS Things to remember: Exact details of the situation are not necessary when dealing sensitive topics. Protect the veteran s privacy. Health (physical or mental): Veteran reported that he/she is currently under a doctor s case for a serious medical condition/illness . Legal, ex-offender (justice involved): Veteran reported that she is currently involved in the legal system . Substance abuse: Veteran disclosed the use of chemical substances that is currently interfering with the ability to be successful in this program .
QUALITY CONTROL Supervisors and quality assurance: In-depth examination of Case Notes and activities to be assured the veteran is receiving the best service(s) possible. Accountability see what, when, why, and how well the veteran is being served. Program Performance (States Veteran Team and United States Department of Labor (USDOL) VETS): Plan versus actual review. Auditors might will review your Case Notes for compliance with state and federal policies and procedures. The impact and effectiveness of the program. Bottom line is if someone can t come in your office, read your last few Case Notes and effectively serve the veteran. If you cannot, then the Case Notes are not being written correctly.
LETS REVIEW A FEW CASE NOTES Take a look at the next few slides and discuss whether or not each sample is an acceptable Case Note or not. New Case Note: Met 22 year old veteran, no identifiable barriers, told him we could not help and he would have to return to the resource room for further assistance. I did escort him back to the resource room. He seems like a very nice person.
CASE NOTE QUIZ New Case Note: Met 33 year old female who claims she is a veteran. I made her show me her DD-214, which was not certified! However, she did say she would be able to obtain one soon. She stated that she did not have any barriers, but did casually mention that she had filed and had a pending claim with the Veterans Administration (VA). I sure would have liked to help her. Oh yes, she is living on a friend s couch; but, she thinks her friend will only let her stay there for one more week.
CASE NOTE QUIZ - PART 2 New Case Note: Because of the giant veteran standup sign near my office, which is near the resource room, a veteran stopped by my office to ask for help. I decided to conduct an Objective Assessment and found he did not have a disability and had not applied for one. He said he had enjoyed the Transition Assistance Program (TAP) class and received compliments from his Commanding Officer that he had written a very good r sum and should have no trouble finding a job. He had never been in jail. He had a General Education Diploma (GED). He had been separated for 38 months; and, although on unemployment, he had only received 22 weeks of assistance. Specifically, he only asked for minor corrections to his r sum and some help on conducting a job search in Employ Florida.
CASE NOTE QUIZ - PART 3 New Case Note: The Disabled Veterans Outreach Program (DVOP) Specialist and veteran with a SBE of low income due to lack of self-sufficient income of less than $11,490. Discussed the use of an Objective Assessment in determining possible barriers and limitations to the veteran s employment. DVOP and veteran reviewed the necessary tools within Employ Florida and created the Objective Assessment by identifying areas and services that the veteran can utilize. The results of the assessment are as follows. The veteran is currently looking for employment within the area as a Medical Assistant or Phlebotomist based on her work history and skill set. Veteran states she has recently relocated to the area in search of full time employment. Duties and responsibilities include: drawing blood for tests, transfusions, donations or research; explaining the procedure to patients; and, assisting in the recovery of patients with adverse reactions. The job may include public safety and security, medical based technology, clerical experience, blood collection and understanding the blood bank. The job duties of a Medical Assistant will require her to perform administrative and certain clinical duties under the direction of a physician. Potential for employment is high because of her work history and medical skill set, in which Labor Market Information (LMI) indicates a viable trend in her job goal. The veteran has adequate transportation and her living situation is congruent with other factors in her life; therefore, the veteran is referred to the career center s front-line staff because her skill set and work history makes her work ready.
CASE NOTE QUIZ - PART 4 New Case Note: Initial intake meeting with veteran customer with the following SBE, Low Income (family of three with an income of $3000 last six months). Career Path: veteran has experience in food service, security and driving. Strengths: forklift, security, communication and teamwork. Employment Challenges: lack of a college degree. Employability: veteran is seeking a position as a driver at this time or another higher paying security position. Veteran also stated that he would like to work for the post office. Work History: veteran just recently separated from the Army (12-27) where he served as a cook. Veteran also has driving and security experience. Recent Experience: veteran was a cook in the Army from 2008 to this past year. LMI: not provided. Objective Assessment completed today, the results are as follows: customer s highest grade level is a high school diploma. Current Living Conditions: veteran has a residence. He has a reliable transportation. Next follow-up to be conducted on 3/17.
CASE NOTE QUIZ - PART 5 New Case Note: Veteran in my office at 8am stating he needed assistance with his r sum for an interview he had today at 3pm. Veterans first time to the office. He completed the intake assessment and determine the veteran had no SBEs. Provided the following services: ***189 POS; ***203 OA; ***115 R sum Prep; ***201 Counseling; and, ***123 JD because job the veteran is interested in is not in the system. Assisted the veteran with r sum and conducted a few mock interviews. Veteran departed the center very happy with services he received reroute to his interview. Veteran stated he would follow-up with me post interview. Follow-up: Veteran contacted me at 3:45pm and stated he got the job, Assistant Program Site Coordinator at $56k per year and company truck. Extremely happy with the assistance he received today and states he is going to write the governor about me and the VETS program.
LETS REVIEW CASE NOTE Purpose. Who, What, When, Where, Why. Writing Case Notes. General rules. Documenting delicate topic tips. Quality control. Case Notes sample quiz.
QUESTIONS Veterans Employment Team Caldwell Building 107 E Madison Street Tallahassee, FL 32399 Telephone: (850) 245-7411 JVSGTAREQUEST@deo.myflorida.com
