Demonstrating Documentation Skills Assignment

Demonstrating Documentation Skills Assignment

For each scenario, consider what you would document in the case notes of the client. Read through each possible choice and choose which answer you feel best describes what you would write in their notes. After choosing your answers, read through the choices that you did not choose to see why they do not demonstrate objective documentation.

Demonstrating Documentation Skills Assignment

After reviewing the Demonstrating Documentation Skills document, write a one-page reflection on the process of objective writing in documentation. Include the following:

What observations from the exercise did you make related to documenting client interactions?
What is the role of objectivity in documentation?
For each scenario, write your own statement to include in the client’s case notes as if you were the professional working with that client. Include possible resource ideas for future discussion with the client.

For each scenario, consider what you would document in the case notes of the client.

Scenario 1:

Client: My mother broke her hip about three months ago, and since she got out of the hospital, she’s been living with me. I’ve had to take care of her, and she’s not the easiest person to take care of. I’m really tired and at the end of my rope.

Possible Documentation Options:

A. Client’s mother is ill and demanding of the client. Client is depressed.

B. Client is exhausted from taking care of her mother.

C. Client’s issues are just from her mother staying with her.

If A…Inferring the client’s mother is “demanding” has a negative connotation that could offend the client. Labeling the client as “depressed” implies medical diagnosis, which the Human Services professional is not qualified to do. Resources may not adequately address the problem.

If B…This is an accurate reflection that states the surface level fact as indicated by the client. Using this fact can help accurately find a resource related to help for caregivers.

If C…Using the word “just” suggests the client’s problems are not very significant. There is potential to miss a helping opportunity because of the lack of facts in the case notes.

Scenario 2:

Client: I guess I would like to be more self-confident. I would like to be able to do my best at something and then feel good about the effort. If possible, I would like those positive feelings to come from inside, so that however my family might react, I would know in my own mind that I could take pride in what I did.

Possible Documentation Options:

Demonstrating Documentation Skills Assignment

A. Client would like to be his own judge rather than depending on his family for evaluations.

B. Client has self-doubt, questioning whether he can make his own decisions.

C. Client needs to increase his self-esteem to be able to find value in what he does.

If A…This statement describes what the client said in a simplified version. Resources based on this statement would focus on his sense of self and possibly his family relationships. More factual information would direct the professional to focus on the client’s self-worth.

If B…Referring to the client’s information as self-doubt produces a negative judgment and could detract from specific resources by only focusing on the negative aspects of the client.

Demonstrating Documentation Skills Assignment

If C…Using the word “needs” indicates the professional knows what is best for the client and is solving the problem for him instead of offering choices and helping him find the answer that best suits him. This does not reflect the values of Human Services.

Scenario 3:

Client: Two months ago my husband got a great job opportunity in another state. We were really excited about it, sold our house, moved into a wonderful new home, got the kids settled in, enrolled them in school…then “poof” it was all gone. The company made cut-backs; my husband lost his job; we moved back here; and now we’re living with my husband’s parents. I don’t know what to do!

Possible Documentation Options:

Demonstrating Documentation Skills Assignment

A. Client has experienced a few life changes and is frustrated.

B. Going through all of these experiences one after another has taken a toll on the client and he must be devastated.

C. Client has been through several life changes in a short period of time: spouse’s new job, moving homes and schools for the kids, spouse losing new job, moving back here, and now living with spouse’s parents.

If A…While the client has experienced life changes, this statement minimizes these major life transitions and does not accurately reflect the magnitude of his situation. Focusing on his frustration could cause a lack of specific resources for this client.

If B…This statement infers the client “must be” devastated. It is not the professional’s job to assign a feeling to the client and by doing this the professional could be isolating the client and missing potential areas to help him.

If C…This factual statement is most appropriate. It documents the changes the client has experienced and focuses on what the professional can do—help him find resources for his husband and family.

Scenario 4:

Client: My dad called me last night–I’m about four hours away from home—and he told me how sad he is and how he doesn’t have anyone. This is the second time he’s called this week. We’re very close. We’ve always been close—through everything. I feel badly about being away from him and just dealing with my life here, when he is back home all alone. He needs me, and I feel very guilty and depressed.

Possible Documentation Options:

Demonstrating Documentation Skills Assignment

A. Client’s dad is lonely and client feels responsible. Client is considering moving back home to be with her dad.

B. Client and her dad have a close relationship, even though they are separated by distance. Their primary mode of communication is telephone and client is concerned about the amount of phone calls she is getting from her dad each week.

C. Client feels guilty and depressed that she can’t be with her dad when he is sad and lonely.

If A…If the focus is put on the client moving back home, the resources will not adequately serve the client. She did not say she is moving back home and by inferring this, the professional is missing the chance to help the client and her dad.

If B…Although this statement contains facts, it does not convey the emotion and concern the client has for her dad. By documenting about the use of the telephone, the professional might focus on explaining resources related to other types of communication. The focus is misguided.

If C…Stating the clients feelings shows attention to the client’s needs. Resources or future conversations with the client will be guided by the client instead of the professional’s judgements.

Scenario 5:

Client: My son, Michael, is struggling in school. He needs some type of help but I don’t know what I should do. I want to give him what he needs, but I really have no idea what that even is.

Possible Documentation Options:

Demonstrating Documentation Skills Assignment

A. Client’s son, Michael, needs academic assistance in school.

B. Client believes her son needs extra support in school but does not know what her role is in getting it for him.

C. Client and her son, Michael, need to meet with his teachers to get suggestions for how to help Micael.

If A…This statement puts the focus on Michael, who is not the client. It implies the need for resources is only for Michael.

If B…By restating what the client has said, the professional shows understanding of the immediate situation and what needs to be done in helping her find assistance for her son. Resources will be focused on the client.

If C…This statement directs the client to do something without having an understanding of the problem. The Human Services professional should not tell clients what to do but instead offer choices.

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