1.6 Required Documentation

Created on: 
Nov 30 2020

1.6 Required Documentation

The Required Documentation section includes:

  • 1.6.1 Who is required to document?
  • 1.6.2 Why documentation matters?
  • 1.6.3 When and where to document?
  • 1.6.4 What are the documentation standards?
  • 1.6.5 How to stay objective?
  • 1.6.6 What are the best documentation practices?

1.6.1 Who is required to document?

All WorkFirst Program Specialists (WFPS) and WorkFirst Social Service Specialists (WFSSS) are required to document every interaction with a WorkFirst participant. This chapter explains in detail the importance of documentation for case management duties and the crucial role documentation plays in supporting a participant to engage in WorkFirst activities.

1.6.2 Why documentation matters?

Effective documentation provides a clear and concise description and result of an interaction between the WFPS/WFSSS and the participant. It helps fellow WFPS/WFSSS who must rely on documentation to make decisions or obtain information about a participant's experience. Participants are often under stress and telling their story more than once can be traumatic, and effective documentation allows the participant to identify their needs without having to repeat themselves. Thorough documentation serves as one of the most crucial functions of case management by:

  • Providing enough information to allow for partnership and an opportunity to build an effective case management relationship;
  • Capturing a timeline of the participant's past, present, and future circumstances;
  • Providing context, including barriers and needs without having to ask the participant to repeat their story, including painful parts;
  • Allowing the participant to trust and engage in self-directed participation;
  • Creating a clear picture for other WFPS/WFSSS to review and build from when interacting with the participant;
  • Allowing WorkFirst staff to understand the participant's past, current, and future goals: and
  • Identifying strengths; and building on participant's successes
Note: Documentation should add value to the case, be objective and clear. Documentation should never contain judgement based on statements or opinions.

1.6.3 When and where to document?

Whenever there is an interaction with the participant or on behalf of a participant, the WFPS/WFSSS must document the issues, needs, and actions taken, timely. When working with a two-parent household, document participation discussions with both parties as necessary to develop their Individual Responsibility Plans (IRPs). Be descriptive and document interactions with the participant or other parties involved in their WorkFirst participation, deferral, or exemption. Also, document any time action is taken on their case. Some examples include:

  • In-person or phone conversations
  • During/after the Comprehensive Evaluation and Assessment
  • Case staffings
  • Referrals
  • Support service requests
  • Receipt of email from the participant or a provider
  • Interactions with an AREP, caregiver, or Power of Attorney
  • Interactions with a provider, contractor, or partner
  • Contact with landlords or vendors
  • Scheduling or mailing correspondence

The type of interaction with the participant determines where to document:

  • eJAS Client Notes for most contacts
    • Select the Case Notes type that best captures the contact
  • Comprehensive Evaluation (CE) tool
    • See WFHB section 3.2.1 for more information on creating the CE
  • Social Services Assessments
    • See WFHB section 6.2 for more information on creating an assessment
  • Individual Responsibility Plans (IRP)
    • See WFHB section 3.3.1 for expectations in IRP
  • Case Staffing/Extension Review
  • Sanction Review
  • Time Limit Extension tool
  • Referral
  • Confidential Note Types are crucial to protect the participant's privacy, as well as, adhere to state and federal confidentiality laws for substance abuse, mental health needs and domestic violence. When adding personal/private information into the data systems, staff must follow a "do no harm" approach. See WFHB section 3.7.2.4 for instructions on how to have confidential notes removed from a non-protected note type(s).
Note: Do no harm means; not putting people's safety in jeopardy, always use a confidential note type when documenting the following notes; domestic violence, mental health, substance abuse, and protected health information such as HIV.

1.6.4 What are the documentation standards?

Every interaction must be documented; however, not all documentation requires the same amount of detail and depth. Documentation needs vary based on the type of interaction you have with a participant and builds on the ongoing story and goals of the participant. Types of interactions that should include documentation are as follows:

  • Comprehensive Evaluation/Assessments:
    • Household composition
    • Circumstances that led to TANF application
    • Areas of stability and strength for the family
    • Areas of instability or obstacles identified by the family
    • Identified goals for the family
  • Case Staffing:
    • Who participated and their role with the family
    • Reasons for the staffing (examples: transition from activity to another, good cause determination, celebrate participant's success)
    • Outcome of the staffing and next steps
    • Ongoing plan (IRP, deferral, referrals)
  • IRP Development:
    • Reflect the participant's agreement to a chosen activity and the IRP
    • Activities and hours of participation
    • How transportation and child care are addressed
    • How the IRP is working towards customer goals
    • For two-parent households: document under note type Participation in both cases (e.g. "Participation was discussed and agreed upon with both parties").
  • Support Service Request(s): See WFHB Section 2.2
    • Type of support(s) being requested
    • Discussion about any resources that may currently be available
    • Any lower cost alternatives that might be available
    • How do they plan to take over the ongoing costs in the future
    • Outcome of request:
      • If approved, explanation for the amount provided
      • If denied, explanation for why
  • Other Ongoing Interactions: Describe elements of the situation and document the plan by using:
    • Description: What's the reason for the contact
      • Who was contacted
      • How did the contact occur (in person, phone call, document in ECR)
      • Why is the contact being made
    • Intervention: What was decided during the contact
      • What is the need the participant disclosed
      • Information or suggestions provided
    • Plan/Outcome: What are the participant's next steps
      • When is the next step due
      • Any referrals needed or made

1.6.5 How to stay objective?

Think of the four C's:

  • Be CLEAR:
    • Everyone needs to know what steps have occurred and what may be next on the case for seamless contact if/when the next worker opens the case record
    • Stay away from abbreviations and acronyms
  • Be CONCISE:
    • Personal judgments or opinions don't have a place in documentation
    • Use non-judgmental observations to support interactions and interventions; this includes staying away from "I statements" and other first person notes
  • Be CORRECT:
    • Stay away from blaming the participant, co-workers, or partners in all notes
    • State facts, do not generalize or stereotype
    • Notes from Skype conversations and emails with peers and partners generally need to be summarized and paraphrased for clarity and appropriateness. Be very cautious about cutting and pasting conversations into the notes
    • Use preferred name, gender pronouns in all records and interactions
  • Be CUSTOMER APPROVED:
    • Be willing to read or share what was documented with the participant and co-workers
    • Remember, documentation is written word which reflects everyone is treated with dignity and respect, providing equitable services

1.6.6 What are the best practices in documentation?

  • Description of the current situation, such as, the reason for the interaction, the needs the participant had, and how it was resolved.
  • The expectation for someone unfamiliar to the case to be able to determine the status/issues/next steps for the participant at the next interaction.

Documentation must prove delivery of service with information as follows:

Accurate Objective
Concise Specific
Consistent Substantive
Descriptive Timely

 

Accurate and consistent documentation:

  • Supports program integrity and equitable service delivery
  • Supports case managers in planning, implementing, and delivering services
  • Provides accurate history of all participant requests for support services to explain denials and approvals
  • Provides relevant history regarding employment readiness, barriers, mental health concerns, substance abuse issues, learning needs, and physical disabilities, etc.
  • Highlights the participant's strengths, supports, and what has worked well for them in overcoming obstacles
  • Provides accountability in serving the participant with each interaction

Resources

Related WorkFirst Handbook Sections