Cheat Sheet for Case Note Fields
There are a lot
of check boxes and drop down boxes on the Case Note entry screen and it can be
a little confusing. Here is a handy guide to help you pick the right options
and make our data as accurate as possible.
Service
Date is just like it sounds, it Is the date that you provided the service that
you are describing in the case note regardless of when you are entering the
case note.
**Counselors
– when entering MSGs or credentials earned, the date the client earned the MSG
or credential is used in this field.
**Counselors
– when entering extensions, the date the extension was signed by the client is
the date of service.
That’s
you. Pretty easy, but please do take a second to choose the right option.
Choosing the wrong option can cause errors in reports and make the people
creating and using those reports grumpy, so a little extra care can make a big
difference.
This
box is only to be used if you have provided a service to a client. This means
the client, not the parent, teacher, guardian, grandmother, cousin twice
removed, cat, employer, teacher, para-educator, or baby brother. This box is
only used for tracking purposes in the VR program to identify the last time a
client received a service.
This
is used for IL, but not VR, so leaving it blank or choosing V when working with
a VR client are both acceptable.
·
Most
instructors will only use Orientation, VR Teaching, a technology option, based
on what you teach, or general for everything else.
·
Do
not choose any of the options that start with MSG if you are not a rehab
counselor recording a measurable skill gain.
·
Once
again, please take a second to make sure you are choosing the right option.
There
are 3 headings (level 2) in the middle of the page. These are described below:
VR Pre-Plan Service
VR Pre-Plan Services has several services listed. VR support services are only to be used by VR counselors to support services needed for eligibility or plan development. They are mostly there for authorizations.
The
Potentially Eligible pre-ets services listed in this section are only to be
used for students with disabilities with an approved pre-ets plan (no other VR
support services can be provided to potentially eligible individuals).
VR
Services Provided are services that are available to VR clients as identified
on their VR plan. If a service is not available to check, then talk to the
counselor about this prior to delivering the service. Additional information
and direction on how to select services in this section are below.
Training
Provided is primarily used for IL statistics. A counselor or instructor will
not select these checkboxes when providing services to VR clients.
The
checkboxes in this section are important because they are used in our federal
reporting to show that we provided a particular service to a client in that
quarter. We also report on VR and IL services provided to the public in our
quarterly board packets. A number of these checkboxes relate to services
provided by counselors or purchased, but some of these are almost exclusively
provided by you all. So it is very important that you check the box when you
provide the service.
Several
VR service types overlap and are very similar. You might be providing more than
one service during a service visit. It is important to check all services
provided, but even more important to document in the case note that the service
was provided and the response of the client.
For
example, if you went out to a client’s house and taught cane travel, gave the
person a slate and stylus, and taught them how to use the slate and stylus, you
would want to check both “Disability Related Skills Training” (for the cane
travel lesson) and “Rehabilitation Technology” because you provided the rehab
technology equipment (the slate and stylus) and provided training on the rehab
tech device. The next visit, if you are continuing to work on writing on the
slate, it might seem more logical to consider that “Disability Related Skills
Training.” Obviously since there is overlap in the descriptions, you aren’t
expected to get it “perfect” every time. Use your best judgement and ask your
supervisor if a really unusual situation occurs. Here are some of the
descriptions that RSA provides in their federal reporting directions for
commonly used services and examples to help clarify.
What
RSA says:
Disability-related
augmentative skills training includes but is not limited to: orientation and
mobility; rehabilitation teaching; training in the use of low vision aids;
Braille; speech reading; sign language; and cognitive training/retraining.
Common
Examples:
•
a
cane travel lesson
•
a
braille lesson
•
teaching
a client how to do something with VoiceOver or TalkBack on their phone
What
RSA says:
Training
provided to prepare an individual for work (e.g., work behaviors, getting to
work on time, dress and grooming, increasing productivity, etc.).
Common
examples:
•
providing
training on appropriate social interactions and behaviors
•
providing
training related to time management and keeping appointments
•
providing
training on disability disclosure or how to discuss blindness in a job
interview
What
RSA says:
Rehabilitation
technology (34 CFR 361.5(c)(45)) means the systematic application of technologies,
engineering methodologies, or scientific principles to meet the needs of, and
address the barriers confronted by, individuals with disabilities in areas that
include education, rehabilitation, employment, transportation, independent
living, recreation, home and vehicular modification, other assistive devices
including, but not limited to hearing aids, low vision aids and wheelchairs.
This includes the hardware portion of neuroprosthetic devices, such as cochlear
implants, visual prosthetics, and motor prosthetic devices, but does not
include medical and surgical procedures required for implantation of
neuroprosthetic devices which should be coded as diagnosis and treatment of
impairments.
Rehabilitation
technology includes rehabilitation engineering, assistive technology devices,
and assistive technology services. The term includes the following:
•
a)
Rehabilitation Engineering Services are the systematic application of
engineering sciences to design, develop, test, evaluate, apply, and distribute
technological solutions to problems confronted by VR individuals in functional
areas such as mobility, communications, hearing, vision, and cognition, and in
activities associated with employment, independent living, education, and
integration into the community.
•
b)
Assistive Technology Devices are any items, piece of equipment, or product
system, whether acquired commercially off the shelf, modified or customized,
that is used to increase, maintain, or improve the functional capabilities of a
VR customer.
•
c)
Assistive Technology Services (34 CFR 361.5(c)(6)) are any services that
directly assist an individual with a disability in the selection, acquisition,
or use of an assistive technology device. Services may include:
o
the
evaluation of the needs of an individual, including a functional evaluation of
the individual in his/her customary environment;
o
purchasing,
leasing, or otherwise providing for the acquisition by an individual of an
assistive technology device;
o
selecting,
designing, fitting, customizing, adapting, applying, maintaining, repairing, or
replacing assistive technology devices;
o
coordinating
and using other therapies, interventions, or services with assistive technology
devices, such as those associated with existing education and rehabilitation
plans and programs;
o
training
or providing technical assistance for an individual or, if appropriate, the
family members, guardians, advocates, or authorized representatives of the
individual; and
o
training
or providing technical assistance for professionals (including individuals
providing education and rehabilitation services), employers, or others who
provide services to, employ, or are otherwise substantially involved in the
major life functions of individuals with disabilities, to the extent that
training or technical assistance is necessary to the achievement of an
employment outcome.
Common
examples:
•
delivering,
installing and setting up technology for a client (i.e. NVDA or JAWS on a
computer)
•
completing
a technology skill assessment
•
providing
loaner pool equipment
•
getting
quotes for a braille display
•
providing
someone a Perkins braillewriter or slate and stylus
What RSA says:
Vocational rehabilitation counseling and guidance
includes information and support services to assist an individual in exercising
informed choice and is distinct from the case management relationship that
exists between the counselor and the individual during the VR process.
Purpose: to assist a client through verbal interaction to deal effectively with
important issues or concerns related to VR, which differentiates it from other
types of counseling routinely provided during the VR process.
Common Examples
·
An in-depth conversation involving
career opportunities, such as where a client says he wants to be a machinist
but does not think that is possible, so the client and instructor talk through
ways a blind person could do that kind of job to help the client in making an
informed career choice.
·
Personal adjustment counseling
directly related to the client’s adjustment to blindness and developing a
positive philosophy of blindness.
Remember,
these services can ONLY be used with students with disabilities who have a VR
plan or potentially eligible plan.
Instruction
in self-advocacy (including instruction in person-centered planning), which may
include peer mentoring (including peer mentoring from individuals with
disabilities working in competitive integrated employment).
Common
examples:
•
providing
training on how to talk to professors or employers about blindness
•
training
provided through consumer organizations in the area of self-advocacy
Workplace
readiness training to develop social skills and independent living.
Common
Examples:
•
teaching
independent living skills related to pre-employment such as preparing lunch,
managing medications, and orientation and mobility skills training
•
providing
training on appropriate workplace behaviors, communication skills and social
interactions
• It is best to type up the note in Word or
another word processor and paste it in to ensure you do not lose your work. (Just
remember to put it into the system!)
• Please remember to spell check and review.
(There is nothing worse than reviewing a client’s case notes and reading the
wrong names and information!)
• In deciding what to put in a case note,
imagine that you were kidnapped by aliens and someone else had to continue
working with this client. What would it be important for them to know about
what happened, the client’s response to training, what plans you and the client
have made for moving forward, any specific concerns or strategies that worked
well, etc.
• Remember, if it isn’t case noted, it didn’t
happen. As important as it is for staff to talk to each other about shared
clients in order to provide better and more timely services, we are all really
busy. Case notes are a very useful communication tool. This is one reason you
are expected to have your case notes in the system no later than five working
days after the service date. Another important reason is due to our federal
reporting requirements.