Overview of Client Appointment (Role Plays)

Overview of Client Appointment (Role Plays) and Drafts

Congrats! You all have been hired to Wildwood Case Management Unit as case managers. Your drafts represent client appointments.  You will have five client appointments.  Below are the client appointment descriptions.   (CM = Case Manager; CL = Client; Hx= History; Tx= Treatment; DA=Diagnostic Assessment: PRN = As needed: MI = Mental illness; CD=Chemical Dependency)

1.   CL Appt 1: Initial phone call/inquiry (Chpt. 14,15); – Draft 1 due Monday 10/12

Role-play call to agency from CL. CM takes call, completes New Referral/Inquiry form, schedules appointment for CL to come in for intake interview with CM, First Contact Note (“CL called today because… (mood)… (motivation)… (app’t. made).”and  completes Verification of Appointment form to send CL regarding next mtg. intake/assessment.

2.   CL Appt. 2: Intake/Assessment interview (Chpt. 16) – Draft 2 due Monday 11/2

Role-play CM’s first in-person intake interview with CL (in class right after initial phone call). CM

verifies information taken over phone on New Referral/Inquiry form. CM

completes Intake/Assessment form, as well as any Release of

Information or Referrals necessary. Contact notes completed of intake appt and outcome. CM

sets up next appointment, completes Verification of Appointment form.

“Disposition Planning Meeting”(Chpt.21) – in class

CM brings copy of Planning Conference Notes to review with colleagues for assistance and feedback. Each CM presents case and asks for input from colleagues for possible suggestion on resource for goals. After conference, CM completes Contact Notes (conference recommendations for service planning mtg,).

3.   CL Appt. 3: Intial Service Plan Goals (Chpt. 20, 25) – Draft 3 due Monday 11/16

CM and CL drafts a Initial Service or Goal Plan. This plan is provisional – no signatures required – and will be revised if needed after review/ monitoring meeting. Case contact Notes completed of initial goal planning meeting and Verification of Appt sent for next meet to monitor service plan an update if needed.

4.   CL Appt 4: Mtg. w/CL to Review/ Update Service/Goal Plan (Chpt. 24) – Draft 4 Mon.11/23

CM meets with CL to review  plan, get CL input, ask/answer questions, make revisions in plan, and obtain CL commitment to a plan. CM completes necessary Referral and Release forms, final version of Service or Goal Plan (with signatures) and Face Sheet to place in file, Contact

Note (include CL response to plan, changes, and 4 parts of contact note format: focus, impressions, resolution, next contact & purpose). Verification of Appointments, for next appointment discharge.

Documentation of subsequent CM meetings with CL (Chpt.19,22)

CM writes Fact Sheet, Contact Notes, Referrals, Releases, etc. as necessary for all subsequent meetings with CL to monitor progress, make changes, etc.

6.   CL Appt. 5: Review and Discharge (Chpt.26) – Draft 5 due Monday 12/7

CM meets with CL to review progress on goals, schedules next mtg. CM has final meeting with CL to discuss follow-up arrangements and close case. After this meeting CM types Discharge Summary, (see p. 411), Discharge Letter to CL, and final Contact Note summarizing this meeting, main points discussed, follow-up arrangements, CL response, etc.

Due Date for Final Case File is 12/17

OTHER COMMONLY USED DOCUMENTATION FORMATS

D.A.P. NOTE – VERSION 1  D = Describe  A = Assess  P = Plan
  D.A.P. NOTE – VERSION 2  D = Data  A = Assess  P = Plan

OTHER:                                                                                                   

*Note other documentation formats used in agency/regional area

OTHER:                                                                                                   

*Note other documentation formats used in agency/regional area

FORMATS USED IN DOCUMENTING CONSUMER PROGRESS S. O. A. P. NOTE

S = Subjective or summary statement by the client. Usually, this is a direct quote. The statement chosen should capture the theme of the session.

1. If adding your own explanatory information, place within brackets [    ] to make it clear that it is not a direct quote.

♦  Example of session theme: “When he raises his voice, I just . . . what do I do? . . .

Yes, I’ll talk more in group.”

2.  If client refers to someone else’s name, indicate that other person by initials. This makes it clear that the client is the focus, not the person the client is talking about. It also guards against any breeches in confidentiality. This is especially true when a client refers to another client.

♦  Example of client using someone else’s name: “She really made me mad . . . You think I should make an appointment to talk to her? I don’t like dealing with this stuff [case worker S.P.].

3.  If the client didn’t attend the session or doesn’t speak at all, use a dash on the “S” line.

♦  Example: S: —

O = Objective data or information that matches the subjective statement. Descriptions may include body language and affect.

♦  Example: 20 minutes late to group session, slouched in chair, head down, later expressed interest in topic.

A = Assessment of the situation, the session, and the client, regardless of how obvious it might be based on the subjective and/or objective statements.

♦  Example: Needs support in dealing with scheduled appointments and taking responsibility for being on time to group.

♦  Example: Needs referral to mental health specialist for mental health assessment.

♦  Example: Beginning to own responsibility for consequences related to drug use.

P = Plan for future clinical work. Should reflect interventions specified in treatment plan including homework assignments. Reflect follow-up needed or completed.

♦  Example: Begin to wear a watch and increase awareness of daily schedule.

♦  Example: Complete Tx Plan Goal #1, Objective 1.

♦  Example: Consider mental health evaluation referral.

♦  Example: Contact divorce support group and discuss schedule with counselor at next session.

Adapted from work by Larry T. Mark and presented by Donna Wapner, Diablo Valley College. Handout included in materials produced by the Pacific Southwest Addiction Technology Transfer Center, 1999.

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