Lecture # 406:
Written Communication and Case Failures

Providing written communication about cases is an essential responsibility of all professionals who work with clients. It is a succinct and prompt report writing of the important information about a particular client. Client record refers to the collection of all the material of all sources that you have about a particular client. There are three sections to a client record:

1. the objective data or forms that you have received,
2. important documents such as medical testing results, agreements the client has signed, the rehabilitation plan,
3. written entries by the counselor after each contact with the client or other agency.

Meditate Word By Word On These Verses:
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In the third section for written entries there are various entries and these include:

1. a short summary of counseling sessions,
2. contacts via telephone, letters written, or face-to-face contacts - these may include communication with family, employers, or colleagues,
3. notes on decisions made in planning,
4. a summary written every month about the progress of the client's rehabilitation.

Case recording is a professional function. Sometimes rehabilitation counselors ignore it and it is done in haste, without careful writing or key facts. Neglect of recording may be due to the counselor's natural interest in working with people and making progress in rehabilitation tasks. Some counselors simply lack adequate skills to record well.

Good case recording is correlated with good client casework. In the client record, the counselor's work is evident in writing down the most important facts, interpretation of those facts, an understanding of the client and, the construction of a vocational rehabilitation plan. This record can even give the number of contacts and amount of time needed for the rehabilitation of a specific client. Such a written record can be threatening if good performance is lacking. On the other hand, a good written case record is a source of information and shows skill.

1. Why is case recording needed?
(One or more of the following answers may be correct.)
a) to document what a counselor has done with the client,
b) to document that the counselor is working,
c) to fill a client record.

Purposes
Good case notes help the counselor do well in rehabilitation of clients. Faithful recording of information helps the counselor to think about what he has written and if the rehabilitation plan is actually helping the client. The notes are to help the counselor in planning what he is going to do next and help his memory.

The case record helps an agency or private association to know if the work it does is effective. If a government agency needs to review the records for some reason, the records, actions of the counselor, and the results are clear to everyone. These records are not for publication and need to be kept confidential.

The case record needs to be in a useful format in the event that colleagues may need to use it for an example as they learn to write case records. It is also useful in helping the counselor learn to improve effectiveness in helping clients. By reviewing previous records, he can understand what he did to help a client be successful in finding work. He sees what procedures worked and what were not helpful.

A supervisor can use the case record to help the counselor grow in his profession. By reviewing the cases and the notes together, the supervisor can point out positive aspects of the counselor's work and those parts of his work that need improvement.

The case recording is also used for evaluation. The supervisor makes decisions about pay raises, assignments of clients, and promotion of the counselor by reviewing the case records. The rehabilitation agency also measures its effectiveness in rehabilitation by what the counselors write in their case notes. One agency may be compared to another on the basis of clients placed in a job, the process of rehabilitation, and what is contained in the case notes. All this information helps the rehabilitation agency to improve its service to handicapped persons.

The critical uses of case recording as listed below:

1. As a professional tool, forcing the counselor to reflect after each client contact in order to better understand the client and the information about him.
2. As a case review for the counselor's future use like a memory aid for the purpose of planning and preparation for meeting with the client.
3. As documentation of evidence of action taken for the client.
4. As an interagency communication in the event that your client will use the services of another agency.
5. To aid in the professional development of the counselor by review of his work with his immediate supervisor.
6. To assess the counselor in review of professional performance and productivity by his supervisor.
7. To aid in training other counselors - when the case recording is especially good.
8. To help with research of an agency to find out if the program they have is effective or not and whether its program meets the goals it set.
9. To help the agency discover better professional techniques that might help other counselors or clients.

Match the following:
A. Professional tool,   B. Research,   C. Case review.

2. used by a rehabilitation agency to determine if they have an effective program.
A, B, C.

3. helps with planning and preparation to meet with a client.
A, B, C.

4. helps a counselor try to understand his client better.
A, B, C.

Problems
Sometimes it is difficult to write case notes simply because of the amount of time it takes and the need to be organized about what is written. Counselors osmetimes have the attitude that was they write will be used against them. Most often the ability to select and organize what to wrtie is a learning process. What is needed is the ability to think about the client's needs, the client's circumstances, and the goals of the rehabilitation plan.

The reasons why case recording breaks down are many:

1. A lack of organization to the rehabilitation process. There is a systematic approach to follow - "study, diagnose, plan, review". If this approach is followed, the counselor will be more successful.
2. Lack of standards for casework in a rehabilitation agency. Clear guidelines are needed for the counselor to know what is expected of him.
3. Poor case management techniques may be the result of a counselor being too busy to properly record his work.
4. Indecisiveness by the counselor means that he may be afraid to make decisions and record them on paper.
5. Lack of case written guides for the counselor to follow as a pattern for his own case recording.
6. Lack of training may cause a person not to record properly. He needs help from his supervisor to know what to do and how to do it.
7. Aversion to recording. We use computers to record our notes. For some people, a computer is not available, thus writing all of the material is difficult. Another problem with writing is that it must be legible with minimum, choice words. Sometimes then we are too minimal and miss the important parts of a report.

Styles of Record Keeping
Usually, there is a preferred style of recording that is recommended by the agency where one works. If everyone uses the same style, reports and notes easy for everyone to read.

The first is an Established Form. These are the fact sheets that are completed when we meet the client and they have such information as medical and social history or work history. These are useful for gathering client information in a uniform manner. Again, computers often are used to store this information from the forms that the counselor completes. The stored information can be printed out and given to the counselor for his personal working file.

A Summary Recording is a condensation of what the counselor and the client have done over a period of time. Such recording is perhaps a summary events that occurred (such as a series of contacts for a job) or more information about the client's character and how he sees the world around him. Perhaps he has seen the doctor and the counselor wants to summarize what the results of the examination were in relation to the rehabilitation goals. Changes in the client's situation or his goals can also be noted in this type of recording. This recording is not about the client's progress toward his goal.

The Narrative Recording is a sequential story about the client and what the counselor have done toward the rehabilitation goal. It may include factual information about the client's problems, actions and motivations. It gives a clear picture of his relationship to his family, former employers, friends, and persons of authority. Dates for each entry are recorded and the counselor gives an opinion of what he/she thinks is happening to the client. For example, the counselor may write: "Client visited seven employers this week. Two employers said that they might have work for him in the next two weeks. The jobs are in factories where candy and coffee are produced. The client is not happy about these jobs, but he thinks he can do them. He would rather work as a dispatcher for factory. However, he also needs to work to get experience. With experience, he may be able to eventually find the job he wants or be promoted to the dispatcher job in the factory."

The narrative may be short or long and abbreviations may be used. It is extremely important that the recording differentiate between is what is observed and the counselor's conclusions drawn from the observations.

Match the style of record keeping with the definitions:
A. Narrative recording,   B. Summary recording,   C. Established forms.

5. fact sheets that are completed about the client.
A, B, C.

6. a sequential story about what has been done to achieve the rehabilitation goal.
A, B, C.

7. a brief description of a change in the client's home situation.
A, B, C,

Principles of Case Recording
Case recording can be done in any style that the counselor wishes. The record becomes an integral part of the procedure of rehabilitation. Using the information recorded, the counselor helps the client through the process of rehabilitation.

Here are some principles of case recording:

1. Case records need to be accurate and meaningful.
2. Case records should reflect the work plan of the client, how well he is doing, and what the plan is accomplishing.
3. The record should contain the type of material that gives a proper view of the client. The length of the record does not determine its usefulness. Relevant material needs to be selected by the counselor. Do not add material just because you have received it. It must apply to the goals you and the client have determined.
4. The data need to be written in the simplest and most economical form, but convey what must be said.
5. Technical terminology must be used carefully. Be sure you understand the terms that you write.
6. Keep the case record up to date so that summaries are easy to write.
7. Keep the facts about the client and your perceptions clearly distinguished from one another.

Case records have two types of writing: descriptive (factual) and interpretive (inferences made from the client or his records). As the rehabilitation plan progresses, the counselor makes interpretations, acts on them, and checks the interpretations if the situation changes. For example, a counselor may decide that a person who has finished high school can do some simple bookkeeping since that was an interest of the client. However, when the client cannot do some basic arithmetic problems, that interpretation of the client's desire has to change. This client cannot do simple bookkeeping.

Confidentiality
Usually, a medical record is a legal document and the rehabilitation case record should be considered in the same way. Be careful about labeling the client if you do not have proper records to refer from. For example, a counselor may read that a client has a diagnosis of autism, but the medical record does not say that. Perhaps the counselor got the diagnosis verbally from a doctor. Be careful of what you write as fact.

Writing Style
Writing by a counselor is similar to the recording that is done in business writing. The aim of writing is to give the readers the information they need in the most efficient, direct way possible. Here are some guidelines:

1. Unnecessary words need to be avoided. If two or three words can be used to accurately say what happened, use them rather than ten words.
2. Simple and familiar words are preferable to long, polysyllable words. For example, it is preferable to say "The client does not want to work" rather than "The client's motivation in terms of employment activity is low."
3. Active verbs are more direct and forceful than passive verbs. Thus, "Mr. Jones was seen on March 1" is less direct than, "I saw Mr. Jones on March 1".
4. Concrete language and descriptive detail should be used. For example, "Mrs. Kuznetsova seemed nervous" is a general statement. A more descriptive statement would be "Mrs. Kuznetsova jiggled her leg and turned frequently".
5. Short sentences are preferable to long ones. Each sentence should express one thought or two thoughts that are closely related.
6. A variety of sentence lengths will help keep the writing from becoming monotonous.

With effort and practice, a counselor is able the think more clearly and communicate more effectively in writing.

8. The aim of writing is to:
(Only one of the following answers is correct.)
a) help the reader know what is happening with the client,
b) show how much the counselor knows,
c) be descriptive.

Case Failure
There are times when you try to help a client and he is unable to follow the plan you make with him or he simply does not respond to telephone calls or other ways you use to contact him. For various reasons people may not try to reach the objectives they really believe are desirable.

The client may be apprehensive about taking chances. To do something new is difficult for many people. Doing new things or merely contemplating changes such as a new job or training program gives a person anxiety. Even if slight changes are made slowly, the client may reject them.

Another factor is that a client may feel that other people are dominating him and exerting force on his personality. If he feels that fate controls him, he will be reluctant to make an effort to make changes in his life. The idea of a person shaping his own life through his own energy and accomplishment is beyond his thinking.

Another cause of failure is that the client is getting better payoff by not complying with a rehabilitation plan. Most people will try to change if the prize at the end of training or a job search is valuable enough. People do not work for change unless they believe the new behavior they display will bring positive results, i.e., the new is more enjoyable than the old. If a person thinks that his group status as a disabled person give him enough money to get what he needs, why does he need to change?

If a counselor has such a client, a frank discussion is needed. Perhaps rehabilitation for work needs to end for a while or the client needs to make a decision about what he really wants. The counselor can again be accepting of the client's decision about what he will do - continue or discontinue rehabilitation. If the client decides not to continue, give him your phone number and tell him that if he decides to try again, you would be happy to help him. He may surprise you and come back to visit you after he has a new job!

9. People sometimes reject rehabilitation because:
(One or more of the following answers may be correct.)
a) they are happy with their present circumstances,
b) they are content with low payments of of their pensions,
c) they are afraid of change.