The Pennsylvania Child Welfare Resource Center University of Pittsburgh, School of Social Work

403 East Winding Hill Road Mechanicsburg, PA 17055

Phone (717) 795-9048 Fax (717) 795-8013 www.pacwcbt.pitt.edu

315: Remote Writing Skills for Case Documentation

PARTICIPANT GUIDE

Developed by:

Andrea Merovich Revised by: Joan M. Mosier

The Pennsylvania Child Welfare

Resource Center

University of Pittsburgh, School of Social Work

June 2020

Copyright 2020, The University of Pittsburgh

This material is copyrighted by The University of Pittsburgh. It may be used freely for training and other educational purposes by public child welfare agencies and other not-for-profit child welfare agencies that properly attribute all material use to The University

of Pittsburgh. No sale, use for training for fees or any other commercial use of this material in whole or in part is permitted without the express written permission of The

Pennsylvania Child Welfare Resource Center of the School of Social Work at The University of Pittsburgh. Please contact the Resource Center at (717) 795-9048 for

further information or permissions.

*All names used in this curriculum are fictitious. Any resemblance to actual persons, living or dead, is coincidental.

Acknowledgements

The Pennsylvania Child Welfare Resource Center would like to thank the following people for their assistance in the creation/revision of Writing Skills for Case

Documentation:

Andrea Merovich The Pennsylvania Child Welfare Resource Center Elizabeth Neail The Pennsylvania Child Welfare Resource Center Jonathan Rubin The Pennsylvania Child Welfare Resource Center Joan M. Mosier JM Training and Consulting

Table of Contents Section I: Welcome and Introductions..................................................................................................1

Introduction/Who Am I?.......................................................................................................................... 1

Agenda/Idea Catcher............................................................................................................................... . 2

Section II: Value of Good Case Records/Documentation...................................................................... . 4

Pennsylvania’s Child Welfare Practice Model.......................................................................................... 4

Knouse Family Case Record..................................................................................................................... . 7

Section III: Writing Skills...................................................................................................................... . 8

Writing Skills Exercise............................................................................................................................... 8

McAbee Case Scenario Notes................................................................................................................. 10

Section IV: Advanced Writing Skills: Relevance and Thoroughness..................................................... 11

What to Record...................................................................................................................................... 11

Distinguishing Fact and Opinion............................................................................................................. 13

Martin Family Case Vignettes Notes Page.............................................................................................. 14

Use of Language..................................................................................................................................... 15

Effective Documentation........................................................................................................................ 16

Section V: Skill Building...................................................................................................................... 18

Emilio Video Activity Notes.................................................................................................................... 18

The Six Domains..................................................................................................................................... 19

Section VI: Review and Evaluations.................................................................................................... 23

Transfer of Learning............................................................................................................................... 23

References............................................................................................................................................. . 24

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Introduction/Who Am I?

Tell us your:

Name County

Position

Number of years with the Agency

Your personal goal for the course

Training Room Guidelines:

• The 15-Minute Rule • Training Schedule – 9:00 to 4:00 with breaks/lunch • Document your presence via the sign-in sheets • Provide constructive and motivational feedback • Show respect • Take risks • Practice makes permanent • Focus on learning – Cell phones on vibrate and only contact office for

emergencies

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Agenda/Idea Catcher

Don’t let a good idea get away!

Research shows that people remember 20% of what they hear, 30% of what they see, 70% of what they say and 90% of what they do! If you use an idea within 24 hours of learning it, you’re more likely to integrate it permanently. As you proceed through the sections of the workshop, if you hear or think of an idea or concept that you want to use, write it down in the spaces provided.

Section I: Welcome and Introductions

___________________________________________________ ____________________________________________________________________________________________________________________________________________________________

Section II: Value of Good Case Records/Documentation

___________________________________________________ ____________________________________________________________________________________________________________________________________________________________

Section III: Writing Skills

___________________________________________________ ____________________________________________________________________________________________________________________________________________________________

Section IV: Advanced Writing Skills: Relevance and Thoroughness

___________________________________________________ ____________________________________________________________________________________________________________________________________________________________

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Section V: Skill Building

___________________________________________________ ____________________________________________________________________________________________________________________________________________________________

Section VI: Review and Evaluations

___________________________________________________ ____________________________________________________________________________________________________________________________________________________________

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Pennsylvania’s Child Welfare Practice Model

Outcomes: Children, youth, families, child welfare representatives and other child and family service partners participate as team members with shared community responsibility to achieve and maintain the following:

Safety from abuse and neglect Enduring and certain permanence and timely achievement of stability,

supports and lifelong connections Enhancement of the family’s ability to meet their child/youth’s well-being,

including physical, emotional, behavioral and educational needs Support families within their own homes and communities through

comprehensive and accessible services that build on strengths and address individual trauma, needs and concerns

Strengthened families that successfully sustain positive changes that lead to safe, nurturing and healthy environments

Skilled and responsive child welfare professionals, who perform with a shared sense of accountability for assuring child-centered, family-focused policy, best practice and positive outcomes

Values and Principles: Our values and principles will be consistently modeled at every level and across partnerships. We believe in…

Children, Youth and Families

o Children and youth have the right to live in a safe, nurturing and stable family o Families are the best place for children and youth to grow up o Family connections are maintained whenever possible o All families have strengths o Families come in all shapes and sizes and family defines family o Families are experts on themselves, are involved in decision making, and are

willing to drive change

Community o Community is broadly defined. This includes, but is not limited to,

families, neighbors, volunteers, spiritual, educational, medical, behavioral health and legal partners.

o Natural partnerships must exist within a community to promote prevention, protection, well-being and lifelong connections

Honesty o Honesty serves as the basis for building trusting relationships o Honesty is not only telling the truth, but also sharing information, clarifying

roles and responsibilities and transparent decision making o Honesty is an open and consistent exchange of communication in a way that

everyone can understand

Cultural awareness and responsiveness o Culture is respected, valued and celebrated o Culture is broadly defined. This includes but is not limited to families’ beliefs,

values, race, gender, socio-economic status, ethnicity, history, tribe,

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religion/spirituality/affiliations, sexual orientation and language. o Cultural identity is explored with the family. Each child, youth and family is

served with sensitivity within their unique context.

Respect o Everyone has their own unique perspective, the right to be heard and

contribute to their success o Every individual is treated with dignity and consideration

Teaming o Children, youth and families are best served through a team approach with

shared responsibilities. All team members have a role and voice. Involving the child, youth, family and extended support networks as active members of the team empowers the family.

o Teams are strength-based and collaborate toward common goals

o Teams change as needed to include all formal and informal supports and resources

o Team members are accountable for their actions, keeping commitments and following through with agreed upon responsibilities

Organizational excellence o Engaging children, youth and families, as an involved part of an accepting

and empathetic team who can confront difficult issues, will effectively assist in the process toward positive change

o Advocating for and empowering children, youth, families and communities strengthen the organization

o Building, supporting and retaining a qualified, skilled and committed workforce whose own well-being and safety are valued is essential

o Responsible allocation and management of resources demonstrates accountability

o Quality practice is assured by consistently monitoring and improving performance through critical self-reflection and accountability

Skills: To achieve our desired outcomes and commitment to these values and principles, demonstration of the following skills is essential across all aspects of the child welfare system.

Engaging: Effectively establishing and maintaining a relationship with children, youth, families and all other team members by encouraging their active role and voice and successfully accomplishing sustainable shared goals

Teaming: Engaging and assembling the members of the team, including the family, throughout all phases of the change process and based on current needs and goals. Teaming is defining and demonstrating a unified effort, common purpose and clear roles and responsibilities that support positive change.

Assessing and Understanding: Gathering and sharing information so the team has a common big picture of the strengths, challenges, needs and underlying issues. Assessing includes thinking critically and using information to keep the team’s understanding current and comprehensive.

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Planning: Applying information gathered through assessment and monitoring to develop an individualized well-reasoned sequence of strategies and supports to achieve the agreed upon goals

Implementing: Actively performing roles to ensure the formal and informal resources, supports and services, identified in the plan, occur in a timely manner and with sufficient intensity, frequency and sequence to produce sustainable and beneficial results

Monitoring and Adjusting: Continuously analyzing and evaluating the impact and effectiveness of the plan implementation and modifying accordingly in response to the changing successes and needs until goals are achieved

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Knouse Family Case Record

Met with Samuel and Sophie. Samuel took me into his bedroom to show me his toys and games. We sat on the floor and played Connect Four and then played a game of Go Fish with his Thomas the Tank Engine cards Samuel had received for Christmas from Mark. Samuel then showed me a Lego set he had where you can make trucks, cars, motorcycles, and even a helicopter. Samuel showed me how to make the helicopter which fired spongy bullets. Samuel also showed me Sophie’s dog, Max, who he really likes. Samuel also showed me the tricks Max could do, as well as where Max slept. Sophie had made coffee for us, so we sat at their small dining room table and had cookies with our coffee. Sophie said she was happy with how things were going and that Samuel was a good boy. He plays soccer on Saturday mornings at 10am until noon. His grandmother takes him to his matches and watches the games. Sophie wanted to know if we could help pay for Samuel’s upcoming soccer dues and a pair of cleats. Sophie wants to get Samuel a good pair of Nike cleats from Dick’s Sporting Goods that will last longer than the cheap ones from Payless that will probably fall apart half way through the season. Sophie also mentioned that Samuel is doing well in school however is teacher his concerned about his lack of concentration. The teacher at his middle school has said that Samuel daydreams a lot and when the teacher asks him what he is thinking about, he says soccer. Samuel really loved soccer and can’t wait for the season to begin. Samuel wants to have the same coach he had last year, a guy called Butch, who Samuel really liked. Samuel said he likes playing tag at recess at school with his friends Daniel, Thomas, Dante, and Jayden. If there isn’t a game of tag being played, Samuel usually plays basketball or kickball with his friends. Samuel still sees Ellen every Friday afternoon between 3:30 and 4:30 at our office. Jennifer picks Samuel up from school and takes him to therapy, then drops him off at Sophie’s afterwards. John sometimes comes along to the visits with Ellen. I thanked Sophie for the coffee and cookies and told her I might be back in a couple of months. Adapted with permission from CYF Practice Center: http://practicecentre.cyf.govt.nz/policy/recording/key-information/casenote-examples.html#Exampleofapoorcasenote3

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Writing Skills Exercise

The Apostrophe

Brief explanation: __________________________________________________________________________________________________________________________________________________________________________________________________________________ Three helpful hints:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Sample sentence:

______________________________________________________________________

______________________________________________________________________

Number Rules

Brief explanation: __________________________________________________________________________________________________________________________________________________________________________________________________________________ Three helpful hints:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Sample sentence: ____________________________________________________________________________________________________________________________________________

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Quotation Marks

Brief explanation: __________________________________________________________________________________________________________________________________________________________________________________________________________________ Three helpful hints:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Sample sentence: ____________________________________________________________________________________________________________________________________________

Run-On Sentences

Brief explanation: __________________________________________________________________________________________________________________________________________________________________________________________________________________ Three helpful hints:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Sample sentence: ______________________________________________________________________

______________________________________________________________________

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McAbee Case Scenario Notes As you watch the McAbee Case Scenario DVD, please pay particular attention to the sequence of events that occur during Kanesha’s interview with Samantha. Write down the main events discussed in the correct sequence that the interviewee mentions them in the space below.

Notes:

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What to Record

Every county agency in Pennsylvania uses some type of case management system such as CAPS. When using a case management system, you will be prompted to input some of your data electronically. Regardless of which system you use, you will have to document the following areas in your case notes:

Client’s identifying information

Dates, times, and descriptions of contact with the client, family system, and other service providers or organizations

Initial and subsequent psychosocial assessments

Service plan and procedures for monitoring progress toward accomplishment of client’s goals

Services provided and other information about plan implementation

Outcomes of service provisions

Referrals to or from other providers, organizations, or resources, including rationale for referrals, and other collaboration on behalf of the client

Supervision or consultation sought or provided to enhance case management services

Rationale for referrals and transfer or termination of services

Safety Specific Information NOTE: The following bullets have been identified to address all of the safety components that must be addressed in documentation. It is possible to address all of these bullets within the contact summary. If counties opt to document this information in one narrative paragraph, the caseworker and supervisor would need to assure that all of the following bullets have been addressed. If, however, your agency feels that using a template format would be beneficial, this would also be acceptable. o Information gathered for safety assessment

o Documentation specific to the Six Assessment Domains should be included

o Every domain should be considered at each contact; however, information related to two of the domains, type of maltreatment and nature of maltreatment, may not have changed from contact to contact. Caseworkers

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may indicate that no new allegations or maltreatment has occurred since the last contact.

o Changes to the safety assessment and/or safety plan

o Documentation of whether or not the information gathered during this contact resulted in the completion of a new safety assessment worksheet or a revision to the safety plan

Reference the date of the completed safety assessment worksheet or safety plan

Adapted from the National Association of Social Workers. (2013).

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Distinguishing Fact and Opinion

Below is a list of incomplete sentences. Complete each one with the first word that comes to mind. Don’t stop to evaluate what you write or change your first response. If you can’t think of a word or phrase, skip it and go on to the next sentence.

1. Teachers are _____________________________________________________

2. Mothers are ______________________________________________________

3. Children are ______________________________________________________

4. Welfare recipients are ______________________________________________

5. My clients are _____________________________________________________

6. Lawyers are ______________________________________________________

7. Fathers are _______________________________________________________

8. Supervisors are ___________________________________________________

9. Lawmakers are ___________________________________________________

10. Child welfare professionals are _______________________________________

Adapted from: http://www.auburn.edu/~murraba/fact.html

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Martin Family Case Vignettes Notes As you watch the three case vignettes, please take notes in the space provided below as if you were the caseworker.

Notes:

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Use of Language

The Martin Family Case Vignettes: Scenes 4, 5, and 12

Please rewrite the given phrases so that they are better suited to be included in a child welfare professional’s case notes. 1) Ms. Martin seemed irritable.

2) The house was very dirty. 3) Kenny was angry. 4) Jayden and Angel’s biological fathers are absent. 5) Ms. Martin might have a substance abuse problem. 6) Mrs. Martin’s appearance was unkempt. 7) Jayden and Angel are largely unsupervised. 8) Ms. Martin’s mother is a main source of support. 9) Ms. Martin appeared more concerned about meeting her own needs than Jayden

and Angel’s needs.

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Effective Documentation Proficient documentation is essential to assure a child’s safety, well-being, and permanence or testify in court when the author of the case note is not available. Every case note should be written as if it might be read by an attorney, judge, or state or federal reviewer, because such a review could occur. Competent documentation must be objective, accurate, clear, descriptive, relevant, and concise and review the definition of each principal.

Objective information means that the statements are just and reasonable and without expressing bias or prejudice.

o Case records should concisely record what the worker sees, hears, and experiences while working with a family. They should document facts and clear behavioral descriptions.

o Example: “The house was dirty” vs. “There was food and clutter all over

the floor, un-rinsed, dirty dishes piled in the sink and sitting on the table, and the trash was overflowing from the garbage can and creating a noxious odor.”

Accurate information means that the statements are precise and truthful.

o Although errors can and do occur, the author should always strive to check facts, spelling of names, and terms and grammar when documenting the case file.

o If the worker learns that information is incorrect, add updated accurate information to the case record. NEVER erase original information.

Clear information means the reader, a reasonable person, will comprehend the author’s meaning without having to interpret the meaning of any particular jargon or ambiguous phrasing.

o For example instead of stating: “Derek was acting out,” use language that describes the specific behaviors, actions or statements of the person, such as: “Derek skipped school and was caught shoplifting.”

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Descriptive information means that the reader will glean a detailed understanding of the events that occurred.

o Record the date of contact, who was seen, the purpose, and the outcomes in a list or chart.

o It is easier to understand the sequence of contacts and the important outcomes of the visit than if they are buried in a paragraph of description.

Relevant information means providing pertinent, important, and significant information that relates directly to the child’s safety, well-being, and permanency and the family’s functioning and protective capacities.

o Avoid extensive, unnecessary, run-on information.

o Use quotations to paint a vivid, concise picture of the family. Example: “Mrs. Jacobs seems very depressed,” vs. "Mrs. Jacobs said, “Of course I'm depressed. Wouldn't you be if you were in my situation?”

Concise information means that the statements are a brief summary recording of the information and not a process recording.

o Summary recording is a concise summarized description of important

facts and events in the case that enables the reader to quickly discern family's needs, services provided, and outcomes.

o Process recording is the attempt to capture word for word or action by action what occurred during the contact. This “running record” style is often wordy, redundant and confusing, and does not get to important information quickly.

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Emilio Video Activity Notes As you watch the Emilio video, please take notes on your assigned area of relevant documentation in the space provided.

Notes:

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The Six Domains

Type of Maltreatment This is a straightforward information element concerned with facts and evidence, which support the presence of maltreatment, which comes from worker observation, interviews and corroboration. This includes making a conclusion (substantiation) about the type of maltreatment (sexual abuse, lack of supervision, etc.) and the specific symptoms and facts (injuries/constant hitting) which are consistent with the maltreatment.

1. What is the extent of the maltreatment? This question is concerned with the maltreating behavior and the immediate physical effects on a child. It considers what is occurring or has occurred and the results. The answer to this question results in a determination that maltreatment has or has not occurred. This includes decisions regarding allegations of suspected child abuse and allegations regarding the need for general protective services as defined in the Child Protective Services Law (23 Pa. C.S., Chapter 63) and the Protective Services Regulations (55 PA Code, Chapter 3490). However, relying only on information from this question is inadequate for assessing safety. Information that answers this question includes:

o Type of maltreatment o Severity of the maltreatment o History of the maltreatment o Description of specific events o Description of emotional and physical symptoms o Identification of the child and maltreating caregiver

Nature of Maltreatment This qualifies the maltreatment by placing it in a context or situation that l) precedes or leads up to the maltreatment or 2) exists while the maltreatment is occurring. By selectively “assessing” this element separate from the actual maltreatment, we achieve greater understanding of how serious the maltreatment is. In other words, the circumstances that accompany the maltreatment are important and are significant in them and qualify how serious the maltreatment is. 2. What circumstances surround the maltreatment? This question is concerned with the nature of what accompanies or surrounds the maltreatment. It addresses what is going on at the time that the maltreatment occurs or has occurred. Information that answers this question includes:

o The duration of the maltreatment

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o Caregiver intent concerning the maltreatment o Caregiver explanation for the maltreatment and family conditions o Caregiver acknowledgement and attitude about the maltreatment o Other problems occurring in association with the maltreatment

Adult Functioning This information element has strictly to do with how adults (the caregivers) in a family are functioning personally and presently in their everyday lives. It is concerned with life management, social relationships, meeting needs, problem-solving. Among the things you would be concerned about in gathering information and assessing are behavior, communication, ability to relate to others, cognitive functioning, intellect, self-control, problem solving, coping, impulsiveness and stress management. It also includes adult mental health and substance use. It is concerned with whether role performance is influenced by mental health or substance abuse. It includes perception, rationality, self-control, reality testing, stability, self-awareness, self-esteem, self-acceptance and coherence. Remember it is important that recent (adult related) history is captured here such as employment experiences, criminal history, previous relationships and so on. 3. How do the adults within the household function, including substance use and

behavioral health? This question is concerned with how the adults/caregivers in the family feel, think, and act on a daily basis. The question focuses on adult functioning separate from parenting. It is concerned with how the adults in the household function, regardless of whether they are parents or not. Information that answers this question includes:

o Communication and social skills o Coping and stress management o Self-control and rationality o Judgment, problem solving and decision making o Independence o Home and financial management o Employment o Community involvement o Self-care and self-preservation o Substance use o Physical and behavioral health and capacity o Functioning within cultural norms

Child Functioning This information element is qualified by the age of the child. Functioning is considered with respect to age appropriateness. Age appropriateness is applied against the “normalcy” standard. So, it is critical that you have a working understanding of child development given that you will be considering how a child is

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functioning in respect to what is expected given the child's age. Among the areas you will consider in information collecting and “assessing” are trust, sociability, self-awareness and acceptance, verbal skills/communication, independence, assertiveness, motor skills, intellect and mental performance, self-control, emotion, play and work, behavior patterns, mood changes, eating and sleeping habits and sexual behavior. Additionally, you consider the child's physical capabilities including vulnerability and ability to make needs known. 4. How do the children function, including their condition? This question is concerned with a child’s general behavior, emotions, temperament, and physical capacity. It addresses how a child is from day to day rather than focusing on points in time. Information that answers this question includes:

o Capacity for attachment o General mood and temperament o Intellectual functioning o Communication and social skills o Expression of emotions/feelings o Behavior o Peer relations o School performance o Independence o Motor skills o Physical and behavioral health o Functioning within cultural norms

General Parenting When considering this information element, it is important to keep distinctively centered on the overall parenting that is occurring and not allow any maltreatment incident or discipline to shade your study. Among the issues for consideration within this element are: parenting styles and the origin of the style, basic care, affection, communication, expectations for children, sensitivity to an individual child, knowledge and expectations related to child development and parenting, reasons for having children, viewpoint toward children, examples of parenting behavior and parenting experiences. 5. How do caregivers generally parent? This question explores the general nature and approach to parenting which forms the basis for understanding caregiver-child interaction. Information that answers this question includes:

o Reasons for being a caregiver

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o Satisfaction in being a caregiver o Caregiver knowledge and skill in parenting and child development o Caregiver expectations and empathy for a child o Decision making in parenting practices o Parenting style o History of parenting behavior o Protectiveness o Caregiver assures appropriate supervision in his/her absence o Whether another adult is undermining parental authority

Parenting Discipline This is another information element that focuses information collection into one area – discipline of children. Study here would include the parent's methods, the source of those methods, purpose or reasons for, attitudes about, context of, expectations of discipline, understanding, relationship to child and child behavior, meaning of discipline. 6. How do the caregivers discipline the children? This question is concerned with the manner in which caregivers approach discipline and child guidance. This question is broken out from general parenting because this aspect of family life is highly related to both safety threats and risk of maltreatment. Information that answers this question includes:

o Disciplinary methods o Concept and purpose of discipline o Context in which discipline occurs o Cultural practices

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Transfer of Learning

Transfer of Learning is important in helping you to prepare to use the knowledge that you gained in this workshop to your efforts as child welfare professionals. This activity will help you think about how to use the knowledge that you now have and will prepare you to use it on the job. Please complete the following information. If you have any questions, please talk with your trainer.

What are three concepts that you learned today that you can apply to your efforts as child welfare professionals? o ______________________________________________________________

o ______________________________________________________________

o ______________________________________________________________

What handouts, resources, and/or other items/concepts would you want to share with other child welfare professionals in your agency and/or others? o ______________________________________________________________

o ______________________________________________________________

o ______________________________________________________________

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