CHAPTER TWO The Assessment Phase
· Referral, screening, and assessment begin our work with HIV clients. We get a referral, then screen to see if there is a match between the referrals and the family service center. This includes a home visit and verification of HIV status. An assessment of the family follows. Its purpose is to identify needs.
—Caseworker, Bronx, NY
Assessment means appraisal or evaluation of a situation, the person(s) involved, or both. As the initial stage in helping, assessment generally focuses on identifying the problem and the resources needed to resolve it. Focusing on the people who are involved includes attention to client strengths that can be a valuable resource to encourage client participation and facilitate problem solving. The benefits of the strengths-based approach to assessment were discussed in Chapter One . As the opening example shows, data are gathered and assessed at this phase to show the applicant’s problem in relation to the agency’s priorities. Identifying possible actions and services and determining who will handle the case are also part of the assessment phase. In this example, a preliminary screening follows the referral. This chapter explores the assessment stage of the helping process: the initial contact with an applicant for assistance, the interview as a critical component in data gathering, and the case record documentation that is required during this phase. You can refer to Figure 2.1 to see the place assessment has in the helping process. The assessment phase concludes with the evaluation of the application for services. For each section of the chapter, you should be able to accomplish the following objectives.
Application for Service
· ■ List the ways in which potential clients learn about available services.
· ■ Compare the roles of the helper and the applicant in the interview process.
· ■ Define interview.
· ■ Distinguish between structured and unstructured interviews.
· ■ State the general guidelines for confidentiality.
· ■ Define the helper’s role in evaluating the application.
· ■ List the two questions that guide assessment of the collected information.
· ■ Compare the three scenarios of case assignment.
Documentation and Report Writing
· ■ Distinguish between process recording and summary recording.
· ■ List the content areas of an intake summary.
· ■ State the reasons for case or staff notes.
Figure 2.1 The Helping Process
Application for Services
Potential clients or applicants learn about available services in a number of ways. Frequently, they apply for services only after trying other options. People having problems usually try informal help first; it is human nature to ask for help from family, friends, parents, and children. Some people even feel comfortable sharing their problems with strangers waiting in line with them or sitting beside them. A familiar physician or pastor might also be consulted on an informal basis. On the other hand, some people avoid seeking informal help because of embarrassment or fear of loss of face or disappointment.
Previous experiences with helping agencies and organizations also influence the individual’s decision to seek help. Many clients have had positive experiences with human service agencies, resulting in improved living conditions, increased self-confidence, the acquisition of new skills, and the resolution of interpersonal difficulties. Others have had experiences that were not so positive, having encountered helpers who had different expectations of the helping process, delivered unwanted advice, lacked the skills needed to assist them, were inaccessible, or never understood their problems. Increasingly, clients may also encounter local, state, and national policies that may make it difficult to get services. An individual’s other prior life experiences also play a role in the decision to seek help.
An individual who does decide that help is desirable can find information about available services from a number of sources. Informal networks are probably the best sources of information. Family, friends, neighbors, acquaintances, and fellow employees who have had similar problems (or who know someone who has) are people trusted to tell the truth about seeking help. Other sources of information are professionals with whom the individual is already working, the media (posters, public service announcements, and advertisements), the telephone book, and the Internet. Once people locate a service that seems right, they generally get in touch on their own (self-referral).
Other individuals may be referred by a human service professional if they are already involved with a human service organization but need services of another kind. They may be working with a professional, such as a physician or minister, who also makes referrals. These applicants may come willingly and be motivated to do something about their situation, or they may come involuntarily because they have been told to do so or are required to do so. The most common referral sources for mandated services are courts, schools, prisons, protective services, marriage counselors, and the juvenile justice system. These individuals may appear at the agency but ask for nothing, even denying that a problem exists.
The following examples illustrate the various ways referral can occur. The first individual works at a community-based agency.
· The center is open five days a week year round. Our mobile outreach initiative identifies clients. We use a van or bicycles to find and interact with people on the streets who are homeless and need our services.
—Social Worker, St. Louis
The second quote is from a caseworker at an institution that serves the elderly in a large metropolitan city.
· Clients come to us in several ways—from other agencies, through friends, by word of mouth, Medicaid, or the discharge planning staff.
—Caseworker, Bronx, NY
The third works at a community mental health center that coordinates services for clients with chronic mental illness. At this agency, client records are available at referral and provide important information about the client and previous services.
· Our referrals are on paper. From that information I make a determination about fit with our criteria. If there is a fit, one of the case managers will visit the client, who is usually in the hospital. This makes him or her easier to find.
—Case Manager, Los Angeles
The final example is from a program for the homeless in Brooklyn, NY.
· Our clients come from the homeless shelter. One of our programs serves the homeless who have employment skills. Often we go to shelters in town to tell social workers and shelter clients about the program.
—Agency Director, Brooklyn, NY
These examples illustrate the different ways in which a referral occurs. In an institutional setting, referrals are made by other professionals and departments in the institution. In other settings, referrals can also occur in-house or come from other agencies or institutions. Sometimes the referral procedure may include an initial screening by phone ( Figure 2.2 ), a committee deliberation, an individual interview, or the perusal of existing records or reports, or both. Usually, the individual who receives the referral makes sure that the necessary paperwork is included.
Not all applicants who seek help or are referred for services become clients of the agency. Clients are those who meet eligibility criteria to be accepted for services. An intake interview is the first step in determining eligibility and appropriateness.
An interview is usually the first contact between a helper and an applicant for services, although some initial contacts are by telephone or letter. The first helper an applicant talks with may be an intake worker who only conducts the initial meeting, or he or she may in fact be a case manager, helping professional, counselor, or service provider. If the first contact is an intake worker, the applicant (if accepted for services) will also be assigned to a helper, who will coordinate whatever services are provided. In this text, we will assume that the intake interviewer is also the professional who will provide help.
The initial meeting or intake interview, with an applicant takes place as soon as possible after the referral. The interview is an opportunity for the helper and applicant to get to know one another, define the person’s needs or problems, and give some structure to the helping relationship. These activities provide information that becomes a starting point for service delivery, so it is important for the interviewer to be a skillful listener, interpreter, and questioner. First, we will explore what an interview is, the flow of the interview process, and two ways to think about interviews that you may conduct as part of the intake process.
Figure 2.2 Phone Screening Form
Interviewing is a critical tool for communicating with clients, collecting information, determining eligibility, and developing and implementing service plans—in all, a key part of the helping process. Primary objectives of interviewing are to help people explore their situation, to increase their understanding of it, and to identify resources and strengths. The roles of the applicant and the helper during this initial encounter reflect these objectives. The applicant learns about the agency, its purposes and services, and how they relate to his or her situation. The helper obtains the applicant’s statement of the problem and explains the agency and its services. Once there is an understanding of the problem and the services the agency offers, the helper confirms the applicant’s desire for services. The helper is also responsible for recording information, identifying the next steps in the helping process, informing the applicant about eligibility requirements, and clarifying what the agency can legally provide a client. There are three desirable outcomes of the initial interview (Kanel, 2007 ). First, rapport establishes an atmosphere of understanding and comfort. Second, the applicant feels understood and accepted. Third, the applicant has the opportunity to talk about concerns and goals.
EXACTLY WHAT IS AN INTERVIEW?
In the helping process, an interview is usually a face-to-face meeting between the helper and the applicant; it may have a number of purposes, including getting or giving information, resolving a disagreement, or considering a joint undertaking.
An interview may also be an assessment procedure. It can be a testing tool in areas such as counseling, school psychology, social work, legal matters, and employment applications. One example of this is testing an applicant’s mental status. We can also think of the interview as an assessment procedure in which one of the first tasks is to determine why the person is seeking help. An assessment helps define the problems and client strengths, and the resulting definition then becomes the focus for intervention.
Another way to think about defining the interview is to consider its content and process (Enelow & Wexler, 1966 ). The content of the interview is what is said, and the process is how it is said. Analyzing an interview in these terms gives a systematic way of organizing the information that is revealed in the interaction between the helper and the applicant. It also facilitates an understanding of the overall picture of the individual. This is particularly relevant, since many clients have multiple problems. Ivey, Ivey, and Zalaquett ( 2010 ) caution that although the terms counseling and interviewing are sometimes used interchangeably, interviewing is considered the more basic process for information gathering, problem solving, and the giving of information or advice. An interview may be conducted by almost anyone—business people, medical staff, guidance personnel, or employment helping professional. Therapeutic intervention is a more intensive and personal process, often associated with professional fields such as social work, guidance, psychology, and pastoral counseling. Interviewing is a responsibility assumed by most helpers, whereas counseling is not always their job.
HOW LONG IS AN INTERVIEW?
An interview may occur once or repeatedly, over long or short periods of time. Okun and Kantrowitz ( 2008 ) limit the use of the word interview to the first meeting, calling subsequent meetings sessions. In fact, the actual length of time of the initial meeting depends on a number of factors, including the structure of the agency, the comprehensiveness of the services, the number of people applying for services (an individual or a family), and the amount of information needed to determine eligibility or appropriateness for agency services.
A caseworker from a community action agency recalled that she had conducted an intake interview in 15 minutes. “When I was learning to be a helper, I thought I would have the time I needed for the first visit with a client” (Case Manager, Women’s Advocacy, Tennessee).
WHERE DOES THE INTERVIEW TAKE PLACE?
Interviews generally take place in an office at agencies, schools, hospitals, and other institutions. Sometimes, however, they are held in an applicant’s home. Observing the applicant in the home provides the distinct advantage of information about the applicant that may not be available in an office setting. An informal location, such as a park, a restaurant, or even the street, can also serve as the scene of an interview. Whatever the setting, it is an important influence on the course of the interview.
WHAT DO ALL HELPING INTERVIEWS HAVE IN COMMON?
There are commonalities that should occur in any initial interview. First, there must be shared or mutual interaction: Communication between the two participants is established, and both share information. The interviewer may be sharing information about the agency and its services, while the applicant may be describing the problem. No matter what the subject of their conversation is, the two participants are clearly engaged as they develop a relationship.
A second factor is that the participants in the interview are interdependent and influence each other. Each comes to the interaction with attitudes, values, beliefs, and experiences. The interviewer also brings the knowledge and skills of helping, while the person seeking help brings the problem that is causing distress. As the relationship develops, whatever one participant says or feels triggers a response in the other participant, who then shares that response. This type of exchange builds the relationship through the sharing of information, feelings, and reactions.
The third factor is the interviewing skill of the helper. He or she remains in control of the interaction and clearly sets the tone for what is taking place. The knowledge and expertise of the professional helper distinguish the helper from the applicant and from any informal helpers who have previously been consulted. Because the helping relationship develops for a specific purpose and often has time constraints, it is important for the helper to bring these considerations to the interaction, in addition to providing information about the agency, its services, the eligibility criteria, community resources, and so forth.
The Interview Process
The interview’s structure refers to the arrangement of its three parts: the beginning, the middle, and the end. The beginning is a time to establish a common understanding between the interviewer and the applicant. The middle phase continues this process, through sharing and considering feelings, behaviors, events, and strengths. At the end, a summary provides closure by describing what has taken place during the interview and identifying what will follow. Let’s examine each of these parts in more detail.
Several important activities occur at the beginning of the interview: greeting the client, establishing the focus by discussing the purpose, clarifying roles, and exploring the problem that has precipitated the application for services, as well as client strengths. The beginning is also an opportunity to respond to any questions that the applicant may have about the agency and its services and policies. The following questions are those most frequently raised by clients (Weinrach, 1987 ).
How often will I come to see you?
Can I reach you after the agency closes?
What happens if I forget an appointment?
Is what I tell you confidential?
What if I have an emergency?
How will I know when our work is finished?
What will I be charged for services?
Will my insurance company reimburse me?
Answering these questions can lead to a discussion of the applicant’s role and his or her expectations for the helping process.
The next phase of the interview is devoted to developing the focus of the relationship between the interviewer and the applicant. Assessment, planning, and implementation also take place at this time. Assessment occurs as the problem is defined in accordance with the guidelines of the agency. Often, assessment tends to be problem focused, but a discussion that focuses only on the client’s needs or weaknesses, or both, can be depressing and discouraging.
Spending some of the interview identifying strengths can be energizing and can result in a feeling of control. Assessment also includes consideration of the applicant’s eligibility for services in light of the information that is collected. All these activities lead to initial planning and implementation of subsequent steps, which may include additional data gathering or a follow-up appointment.
At the close, the interviewer and the applicant have an opportunity to summarize what has occurred during the initial meeting. The summary of the interview brings this first contact to closure. Closure may take various forms, including the following scenarios: (1) the applicant may choose not to continue with the application for services; (2) the problem and the services provided by the agency are compatible, the applicant desires services, and the interviewer moves forward with the next steps; and (3) the fit between the agency and the applicant is not clear, so it is necessary to gather additional information before the applicant is accepted as a client.
A technique that some helpers find successful as an end to the initial interview is a homework assignment that once again turns the applicant’s attention to strengths. Individuals may be asked questions to help identify the source of their strengths as suggested in Figure 1.7 of Chapter One . Although this type of discussion might occur at any time in the helping process, the value in such a technique at this time is the movement that might occur from problem-oriented vulnerability to problem-solving resilience. It may also solidify the client’s intent to return and promote his or her involvement in the helping process.
Structured and Unstructured Interviews
Interviews may be classified as structured or unstructured. A brief overview of these two types of interviews is given here. Chapter Four will provide more in-depth information about the structured interview in connection with the discussion of skills for intake interviewing.
Structured interviews are directive and focused; they are usually guided by a form or a set of questions that elicit specific information. The purpose is to develop a brief overview of the problem and the context within which it is occurring. They can range from a simple list of questions to soliciting an entire case history.
Agencies often have application forms that applicants complete before the interview. If the forms are completed with the help of the interviewer during the interview, the interaction is classified as a structured one. Of course, this is a good way to establish rapport and to identify strengths, but interviewers must be cautious. The interview can easily become a mere question-and-answer session if it is structured exclusively around a questionnaire. Asking yes/no questions and strictly factual questions limits the applicant’s input and hinders rapport building.
The intake interview and the mental status examination are two types of structured interviews, each of which has standard procedures. Generally, an agency’s intake interview is guided by a set of questions, usually in the form of an application. The mental status examination (which typically takes place in psychiatric settings) consists of questions designed to evaluate the person’s current mental status by considering factors such as appearance, behavior, and general intellectual processes. In both situations, the interviewer has responsibility for the direction and course of the interview, even though the areas to be covered are predetermined. A further look at the mental status examination illustrates the structured interview.
A mental status examination is a simple test that assesses a number of factors related to mental functioning. Sometimes agencies will use a predetermined list of questions. Others may use a test such as the Mini Mental Status Examination (MMSE). Both modalities structure the interview. Whatever the method, generally the focus is on four main components that may vary slightly in their organization: appearance and behavior, mood and affect (emotion), thought disturbances, and cognition (orientation, memory, and intellectual functioning). Some of these components may be assessed by observing the client while others require asking specific questions and listening closely to responses. For example, appearance and behavior are observable and may target dress, hygiene, eye contact, motor movements or tics, rhythm and pace of speech, and facial expressions. On the other hand, thought disturbances are based on what a client tells the examiner and his or her perception of things: “Do your thoughts go faster than you can say them?” “Do you hear voices that others cannot hear?” and “Have you ever seen anything strange you cannot explain?” The examiner takes into consideration factors such as a person’s country of origin, language skills, and educational level. Terms like “high school” and tasks like reciting former U.S. presidents may not be appropriate for all examinees.
As you read the following report, determine the results of the assessment of the four components of a mental status examination:
· “Pops” Bellini arrived for his appointment on time. He was dressed in slacks and a shirt but appeared disheveled, with wrinkled clothing and uncombed hair. He stated that he had been homeless for six months and had not bathed in four days. He wants to work. He rocked forward when answering a question and tightly clasped his hands in his lap. He reported that he is on no medication at the present time, although he has taken “something” in the past for “nerves.” His mood was anxious and tense, wondering if he will be able to find some work. Speech was slow, clear, and deliberate. Initially he responded with a wide-eyed stare. Mr. Bellini often asked that a question be repeated; upon repetition, he provided responses that were relevant to the question. Cognition seemed logical and rational although slow. Mr. Bellini is aware of the need to find work to support himself but is concerned about his ability to perform at a job. He seems most worried about “pressures” that cause him to “freeze.”
In contrast to the structured interview, the unstructured interview consists of a sequence of questions that follow from what has been said. This type of interview can be described as broad and unrestricted. The applicant determines the direction of the interaction, while the interviewer focuses on giving reflective responses that encourage the eliciting of information. Helpers who use the unstructured interview are primarily concerned with establishing rapport during the initial conversation. Reflection, paraphrasing, and other responses discussed in Chapter Four will facilitate this.
Our discussion of the initial meeting would be incomplete if we did not address the issue of confidentiality . Human service agencies have procedures for handling the records of applicants and clients and for maintaining confidentiality; all helpers should be familiar with them. An all-important consideration is access to information.
Every communication during an interview should be confidential in order to encourage the trust that is necessary for the sharing of information. Generally, human service agencies allow the sharing of information with supervisors, consultants, and other staff who are working with the applicant. The client’s signed consent is needed if information is to be shared with staff employed by other organizations. The exception to these general guidelines is that information may be shared without consent in cases of emergency, such as suicide, homicide, or other life-threatening situations.
Applicants are frequently concerned about who has access to their records. In fact, they may wonder whether they themselves do. Legally, an individual does indeed have access to his or her record; the Federal Privacy Act of 1974 established principles to safeguard clients’ rights. In addition to the right to see their records, clients have the right to correct or amend the records. For example, the Department of Health and Human Services retains oversight for the Health Insurance Portability Accountability Act of 1996 (HIPAA), which outlines privacy regulations related to client records within the health care arena (U.S. Department of Health and Human Services, n.d.). The overriding principle of the act is that records belong to the client, not the office or agency in which they are generated or housed. Clients have access to their own records and they determine who else may view them. Agencies and offices must provide clients information about HIPAA (Notice of Privacy Practices) and must secure client authorization for release of all information.
There are two potential problem areas related to confidentiality. First, it is sometimes difficult in large agencies to limit access of information to authorized staff. Support staff, visitors, and delivery people come and go, making it essential that records are secure and conversations confidential (Hutchins & Cole Vaught, 1997 ). The second problem has to do with privileged communication , a legal concept under which clients’ “privileged” communications with professionals may not be used in court without client consent (Corey, Corey, & Callanan, 2007 ). State laws determine which professionals’ communications are privileged; in most states, human service professionals are not usually included. Thus, the helper may be compelled to present in court any communication from the applicant or client. Sometimes it can be a challenge for the helper to explain this limitation to an applicant while trying to gather essential information. It can also be perplexing to the applicant.
Evaluating the Application for Services
During this phase, the helper’s role is to gather and assess information. In fact, this process may actually start before the initial meeting with the applicant, when the first report or telephone call is received, and continue through and beyond the initial meeting. The initial focus on information gathering and assessment then narrows to problem identification and the determination of eligibility for services. This process is influenced to some extent by guidelines and parameters established by the agency or by federal or state legislation. At this point in the process, the helper must pause to review the information gathered for assessment purposes.
Part of the assessment of available information is responding to the following questions:
Is the client eligible for services?
What problems are identified?
Are services or resources available that relate to the problems identified?
Will the agency’s involvement help the client reach the objectives and goals that have been established?
Reviewing these questions helps determine the next steps. To answer the questions and evaluate the application for services, the helper engages in two activities: a review of information gathering and an assessment of the information.
REVIEW OF INFORMATION GATHERING
Usually, the individual who applies for services is the primary source of information. During the initial meeting, the helper forms impressions of the applicant. The problem is defined, and judgments are made about its seriousness—its intensity, frequency, and duration (Hutchins & Cole Vaught, 1997 ). As the helper reviews the case, he or she considers these impressions in conjunction with the application for services, the case notes summarizing the initial contact with the client, and any case notes that report subsequent contacts. The helper learns more about the applicant’s reasons for applying for services; his or her background, strengths, and weaknesses; the problem that is causing difficulty; and what the applicant wants to have happen as a result of service delivery. The helper also uses information and impressions from other contacts. Other information in the file that may contribute to an understanding of the applicant’s situation comes from secondary sources, such as the referral source, the client’s family, school officials, or an employer. Information from secondary sources that can be part of the case file might be medical reports, school records, a social history, and a record of services that have previously been provided to the client.
An important part of the review of information gathering is to ascertain that all necessary forms, including releases, have been completed and signatures obtained where needed. It is also a good idea at this point to make sure that all necessary supervisor and agency reviews have occurred and are documented.
Once the helper has reviewed all the information that has been gathered, the information is assessed. Many helpers have likened this part of the helping process to a puzzle. Each piece of information is part of the puzzle; as each piece is revealed and placed in the file, the picture of the applicant and the problem becomes more complete. Some describe it as “a large body of information from all kinds of different people that you have to sort through in order to identify the real issues.” In addition, a social worker in Houston suggests,
· Sometimes, to be effective, it’s necessary to be sensitive to what is going on and what it means. This is a poor white community with many different subcultures. For example, anyone who works here needs to understand the importance of shamans and spells. Sometimes individuals and families just need a shaman to get rid of the spell. I’ve actually seen some bizarre behavior changes as a result of a shaman’s intervention.
Knowing what information is in the file, the helper’s task shifts to assessing the information. Two questions guide this activity: Is there sufficient information to establish eligibility? Is additional information necessary? In addition to answering these questions, the helper also evaluates the information in the file, looking for inconsistencies, incompleteness, and unanswered questions that have arisen as a result of the review.
IS THERE SUFFICIENT INFORMATION TO ESTABLISH ELIGIBILITY?
To answer this question, the helper must examine the available data to determine what is relevant to the determination of eligibility. The quantity of data gathered is less important than its relevance. Human service organizations usually have specific criteria that must be met to find an applicant eligible. The data must correspond to these criteria if the applicant is to be accepted for services.
The criteria for acceptance as a client for vocational rehabilitation services is a good example. Vocational rehabilitation is a state and federal program whose mission is to provide services to people with disabilities so as to enable them to become productive, contributing members of society. Essentially, the criteria for acceptance for services are the following: the individual must have a documented physical or mental disability that is a substantial handicap to employment, and there must be a reasonable expectation that vocational rehabilitation services will render the applicant fit for gainful employment.
During the assessment phase, a helping professional assesses the information gathered to determine whether the applicant has a documented disability. The next step is to document that the disability is a handicap to employment. Does the disability prevent the applicant from returning to work? Or, if the person has not been employed, does the disability prevent him or her from getting or keeping a job? If the answers are yes, the helper’s final task is to find support for a reasonable expectation that, as a result of receiving services, the applicant can be gainfully employed. This brings us to the second main question in the information assessment activity.
IS ADDITIONAL INFORMATION NECESSARY IN ORDER TO DETERMINE ELIGIBILITY FOR SERVICES?
If the answer is no, the helper and the client are ready to move to the next phase of the helping process. If the answer is yes—that is, additional information is necessary to establish eligibility—a decision is then made about what is needed and how to obtain it. In the vocational rehabilitation example, the helper examines the file for the documentation of a disability. Specifically, the helper is looking for a medical report from a physician or specialist that will establish a physical disability or a psychological or psychiatric evaluation that will establish a mental disability. If the needed information is not in the file, the helper must make arrangements to obtain the necessary reports.
Establishment of eligibility criteria is not the sole purpose of this phase. Data gathered at this time may prove helpful in the formulation of a service plan. Certainly the helper does not want to discard any information at this point; neither does he or she want to leave unresolved any conflicts or inconsistencies. Relevant, accurate information is an important part of the development of a plan. Ensuring relevance and accuracy at this point in the process saves time and effort and allows the helper and the client to move forward without delay.
Once eligibility has been established and the applicant accepted for services, there are three possible scenarios, depending on the particular agency or organization. In all three, the applicant becomes a client who is assigned a helper to coordinate and/or provide services. In many instances, this helper is the same person who handled the intake interview and determination of eligibility. In some agencies, however, there are staff members whose primary responsibility is conducting the intake interview. After a review, the case is then assigned to another helper—the helping professional who assumes primary responsibility for the case and is accountable for the services given to the client, whether provided personally, by other professionals at the agency, or by helpers at a different agency.
A second scenario involves the specialized professional, a term that may refer to either level specialization or task specialization. Level specialization has to do with the overall complexity and orientation of the client and the presenting problem. Is the case under consideration simple or complex? Is it a case of simply providing requested information, or is it a multi-problem situation? Task specialization focuses on the functions needed to facilitate problem resolution. Does the case require highly skilled counseling, or is coordination sufficient?
The third scenario occurs most often in institutions where a team of professionals is responsible for a number of clients. For example, in a facility for children with cognitive disabilities clients interact daily with a staff that includes a teacher, a nurse, an activity coordinator, a helper, a cottage parent, and a social worker. These professionals work together as a team to provide services to each client.
Documentation and Report Writing
Documentation and report writing play critical roles in the assessment phase of the helping process. The main responsibilities facing the helper in this phase are identifying the problem or problems and determining the applicant’s eligibility for services. Documentation of these two responsibilities takes the form of intake summaries and staff notes. Most agencies have guidelines for the documentation of information gathered and decisions made. This section addresses the forms of documentation, their purposes, and how to write them.
Before we discuss intake summaries and staff notes, let’s distinguish between process recording and summary recording.
Process Recording and Summary Recording
A process recording is a narrative telling of an interaction with another individual. In the assessment phase, a process recording shows what each participant has said by an accurate account of the verbal exchange, a factual description of any action or nonverbal behavior, and the interviewer’s analysis and observations. The person making the recording should imagine that a tape recorder and a camera are taking in everything that is heard or seen. Of course, because records are required to be brief and goal oriented, the helper would not attempt an exhaustive description, but this approach helps focus the recorder’s attention on accuracy and impartiality.
Process recording is a useful tool for helping professionals in training. Tape recorders, digital recorders, video cameras, and VCRs are readily available today, but many agencies and organizations don’t have them, and helpers may not have time or authorization to use the equipment. Process recording is still an effective way to hone one’s skills of direct observation.
Process recording is most often used with one-on-one interviews. It includes the following elements:
· ■ Identifying information : names, date, location, client’s case number or identifying number, and the purpose of the interview.
Paulette Maloney saw the client, Rosa Knight, for the first time on Monday, November 5, at the agency. Ms. Knight is applying for services, and the purpose of the interview was to complete the application form and inform her of the agency’s services.
· ■ Observations : description of physical and emotional climate, any activity occurring during the interaction, and the client’s nonverbal behavior.
Ms. Knight appeared in my office on time, dressed neatly in a navy dress. I asked Ms. Knight to come in, introduced myself, shook her hand, and asked her to sit down. Although there was little eye contact, she smiled shyly with her head lowered. In a soft voice, she asked me to call her Rosa. Then she waited for me to speak.
· ■ Content : an account of what was said by each participant. Quotes are helpful here, to the extent that they can be remembered.
I explained to Rosa that the agency provides services to mothers who are single parents, have no job skills, and have children who are under the age of 6. She replied, “I am a single parent with two sons who are 18 months old and 3 years old. I have worked briefly as a domestic.” I asked her how long she had worked and where. She replied that she worked about five months for a woman a neighbor knew. She quit “because the woman was always canceling at the last minute.” She related that one time when she went to work, the house was locked up and the family was out of town. During this exchange, Rosa clasped her hands in her lap and looked up.
· ■ Recorder’s feelings and reactions : sometimes this is called a self-interview, meaning that the recorder writes down feelings about and reactions to what is taking place in the interview.
I was angry about the way Rosa had been treated in her work situation. She appears to be a well-mannered, motivated young woman who genuinely wants a job so that she can be self-supporting. Her shyness may prevent her from asserting herself when she needs to. Her goal is to get out of the housing project. I wonder if my impressions are right.
· ■ Impressions : here the recorder gives personal impressions of the client, the problem, the interview, and so forth. It may also be appropriate to make a comment about the next step in the process.
Rosa Knight is a 23-year-old single mother of two sons, ages 18 months and 3 years. She has worked previously as a domestic. Particular strengths seem to be motivation and reliability. Her goal is to receive secretarial training so that she can be self-supporting and move from the projects. Based on the information she has provided during this interview, she is eligible for services. I will present her case at the next staff meeting to review her eligibility.
The other style of recording, summary recording , is preferred in most human service agencies. It is a condensation of what happened, an organized presentation of facts. It may take the form of an intake summary or staff notes (both discussed later in this section).
Summary recording is also used for other types of reports and documentation. For example, a diagnostic summary presents case information, assesses what is known about the client, and makes recommendations. (See the Report for Juvenile Court in Chapter Eight .)
A second example is problem-oriented recording, which identifies problems and treatment goals. This type of recording is common in an interdisciplinary setting or one with a team structure. (An example is the Psychological Evaluation, also in Chapter Eight .)
Summary recording differs from process recording in several ways. First, a summary recording gives a concise presentation of the interview content rather than an extensive account of what was said. The focus remains on the client, excluding the interviewer’s feelings about what transpired. Summary recordings usually contain a summary section, which is the appropriate place for the writer’s own analysis. Finally, summary recording is organized by topic rather than chronologically. The interviewer must decide what to include and omit under the various headings: Identifying Information, Presenting Problem, Interview Content, Summary, and Diagnostic Impressions.
Summary recording is less time-consuming to write, as well as easier to read. It is preferred for these reasons, not to mention the fact that it uses less paper, thereby reducing storage problems. Where computerized information systems are used, a standard format makes information easy to store, retrieve, and share with others. A reminder is in order here: agencies often have their own formats and guidelines for report writing and documentation. Generally speaking, however, the basic information presented here applies across agency settings.
An intake summary is written at some point during the assessment phase. It is usually prepared following an agency’s first contact with an applicant, but it may also be written at the close of the assessment phase. For purposes of illustration, assume that it is written after the intake interview. At this point, the interviewer assesses what was learned and observed about the applicant. This assessment takes into account the information provided by the applicant; the mental status examination, if appropriate; forms that were completed; and any available information about the presenting problem. Client strengths are also identified at this time. The interviewer also considers any inconsistencies or missing information. While integrating the information, the interviewer also considers the questions that are presented in the previous section. Is the applicant eligible for services? What problems are identified? Are services or resources available that relate to the problems identified? Will the agency’s involvement improve the situation for the applicant?
This information is organized into an intake summary, which usually includes the following data:
· ■ Worker’s name, date of contact, date of summary
· ■ Applicant’s demographic data—name, address, phone number, agency applicant number
· ■ Sources of information during the intake interview
· ■ Presenting problem and client strengths
· ■ Summary of background and social history related to the problem
· ■ Previous contact with the agency
· ■ Diagnostic summary statement
· ■ Treatment recommendations
The sample intake summary on next page is from a treatment program for adult women who are chemically dependent (see Figure 2.3 ). To qualify for the residential program, applicants must have a child who is three years of age or less and has been exposed to drugs. The day program is available to mothers who have a child older than three years. The applicant whose intake is summarized in Figure 2.2 is applying to the residential program, which lasts one year. During this time children live with their parent in one of 10 agency apartments. To graduate from the program, the client must be employed or enrolled in school and be free of substance abuse. Some individuals enter the program voluntarily, and others are ordered to come as part of their probation. On admission, a staff member conducts a 30-minute interview, which is written up and placed in the client’s file within two days. The client then receives an orientation to the program and is assigned a care coordinator in charge of that case. The care coordinator and the client then have a more extensive interview, lasting approximately 90 minutes.
Figure 2.3 Intake Summary
Staff notes , sometimes called case notes , are written at the time of each visit, contact, or interaction that any helping professional has with a client. Staff notes usually appear in a client’s file in chronological order. They are important for a number of reasons:
· ■ Confirming a specific service : The helper wrote, “John missed work 10 of 15 days this month. He reported that he could not get out of bed. I referred him to our agency physician for a medication review.”
· ■ Connecting a service to a key issue : The helper may write, “I observed the client’s interactions with peers during lunch,” or “I questioned the client about his role in the fight this morning.”
· ■ Recording the client’s response : “Mrs. Jones avoided eye contact when asked about her relationship with her family,” “Janis enthusiastically received the staff’s recommendation for job training,” or “Joe resisted the suggestion that perhaps he could make a difference.”
· ■ Describing client status : Case notes that describe client status use adjectives and observable behaviors: “Jim worked at the sorting task for 15 minutes without talking,” and “Joe’s parents were on time for the appointment and openly expressed their feelings about his latest arrest by saying they were angry.”
· ■ Providing direction for ongoing treatment : Documenting what has occurred or how a client has reacted to something can give direction to any treatment. “During our session today, Mrs. Jones said she felt angry and guilty about her husband’s illness in addition to the feelings of sadness she expressed at our last meeting. These feelings will be the focus of our next meeting.”
The format of case notes depends on the particular agency, but they are always important. For instance, one substance abuse treatment facility uses a copy of its form for each client every day. A helper on each of the three shifts checks the behavior observed and makes chronological case notes on the other side. These notes allow the professionals working with a client to stay up to date on treatment and progress and provide the means of monitoring the case.
There are a number of other case note models, such as data, assessment, and plan (DAT), functional outcomes reporting (FOR), and individual educational programs (Cameron & Turtle-Song, 2002 ). These are all variations of the original SOAP format, originally developed by Weed ( 1964 ). SOAP is an acronym for subjective, objective, assessment, and plan. Developed to improve the quality and continuity of client services by enhancing communication among professionals, SOAP supports the identification, prioritization, and tracking of client problems so they can receive attention in a timely fashion (Kettenbach, 1995 ).
Subjective and objective aspects are both parts of data collection. Subjective refers to information about the problem from the client’s perspective or that of other people: “reports difficulty getting along with her coworkers” or “mother complains about client losing control and striking younger sister.” The helper’s observations and external written materials make up the objective component that is written in quantifiable terms: “client seemed nervous, as evidenced by repeatedly shifting in chair, chewing nails, rocking, and looking down.” The assessment section combines both previous sections for interpretation or a summarization of the helper’s clinical thinking regarding the problem. This is often stated as a psychiatric diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders IV, Text Revision(DSM-IV-TR; American Psychiatric Association, 2000 ) (discussed in Chapter Eight ). The last section of the SOAP notes is the plan, which generally includes both action and prognosis: “next appointment is 5/25/05 @ 10 P.M.; prognosis is good due to motivation for and interest in changing anger behavior. Client also referred to anger management group for weekly meetings.”
Another format for case notes is illustrated by the notes presented next, from a residential treatment facility for emotionally disturbed adolescents. These notes are in the file of a 15-year-old female client who is thought to have a borderline personality disorder. At this facility, a staff person from each shift is required to make a chart entry; the abbreviations DTC, ETC, and NTC refer to day, evening, and night treatment helpers. Any other staff member who has contact with the client during the day (such as the therapist, teacher, nurse, or recreation specialist) also writes a staff note. The word level refers to the number of privileges that a client (ct.) has. For example, a client at Level 1 has a bedtime of 9 P.M.; a client at Level 3 would go to bed at 10 P.M.
This residential treatment facility gives its staff members strict guidelines for charting and consistent abbreviations: ct. to mean client, cue to mean a warning, and C to signify a consequence. Also, there must be no blank lines or spaces in a case note, so the recorder puts in the line and signature at the end of each entry. Note also that no names of other clients or staff members appear in any entry. Notes such as these are routinely reviewed by the helper.
You will also note that the word appropriate appears often. In this facility, it is an important word because these clients often behave and interact inappropriately. It is common for them to act out sexually, exhibit interpersonal difficulties, and rebel against any rules or authority figures.
The assessment phase of the helping process includes the initial contact with the individual or individuals who need or desire services, the intake interview to gather data, and the documentation that is required. Evaluating the application for services concludes the phase.
Applicants learn about services in different ways, which often result in a referral. The first step in determining eligibility for services is the intake interview, which may be structured or unstructured. The intake interview is an opportunity to establish rapport, explore the needs or problems, identify client strengths, and give some structure to the relationship.
Case assignment follows acceptance for services and may occur in one of three ways. First, the helper who conducts the intake interview may be assigned the case. Second, the case may be assigned to a specialized worker who may provide either complex services (level specialization) or specific services (task specialization). Finally, a team of professionals may be responsible for a number of clients.
Documentation and report writing are important parts of the assessment phase. Two different types of documentation are process and summary recording. Intake summaries and case notes are examples of the documentation that occurs in this phase.
Now it’s your turn to practice the concepts introduced in Chapter Two . You can review the key terms and answer the following questions.
REVIEWING THE CHAPTER
How does a person’s previous experience with human service agencies influence his or her decision to seek help?
In what different ways do people learn about available services?
Distinguish between the terms applicant and client.
What purposes does the interview serve?
Describe the roles of the helper and the applicant during the initial meeting.
Discuss different ways to define interview.
What is the difference between interviewing and counseling?
List the three factors common to all interviews.
Describe what takes place in each of the three parts of an interview.
Give three examples of issues that applicants may raise during the initial interview.
Explain why intake interviews and mental status examinations are structured interviews.
What does a helper need to know about confidentiality in the assessment phase?
Discuss the two problem areas related to confidentiality.
What questions guide the assessment of the information gathered during this first phase of the helping process?
Describe case assignment.
Compare process recording and summary recording, and provide an example of each.
What purposes do staff notes (case notes) serve?
Describe the SOAP format and its components.
QUESTIONS FOR DISCUSSION
Why do you think the interview is an important part of the helping process?
What evidence can you give that a good assessment is vital to the helping process?
Speculate on what could happen if a client’s confidentiality was violated.
Develop a plan to interview a client who has applied for public housing.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision). Washington, DC: Author.
Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80, 286–292.
Corey, G., Corey, M. S., & Callanan, P. (2007). Issues and ethics in the helping professions (6th ed.). Pacific Grove, CA: Brooks/Cole.
Enelow, A., & Wexler, M. (1966). Psychiatry in the practice of medicine. New York: Oxford Press.
Hutchins, D. E., & Cole Vaught, C. (1997). Helping relationships and strategies (3rd ed.). Pacific Grove, CA: Brooks/Cole.
Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional interviewing and counseling: Facilitating client development in a multicultural society (7th ed.). Pacific Grove, CA: Brooks/Cole.
Kanel, K. (2007). A guide to crisis intervention (3rd ed.). Pacific Grove, CA: Brooks/Cole.
Kettenbach, G. (1995). Writing SOAP notes. Philadelphia: Davis.
McQuaide, S., & Ehrenreich, J. H. (1997). Assessing client strengths. Families in society, 78(2), 201–212.
Okun, B. F., & Kantrowitz, R. E. (2008). Effective helping: Interviewing and counseling techniques (7th ed.). Pacific Grove, CA: Brooks/Cole.
U.S. Department of Health and Human Services (n.d.) HIPAA. Retrieved from http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html .
Weed. L. L. (1964). Medical records, patient care and medical education. Irish Journal of Medical Education, 6, 271–282.
Weinrach, S. G. (1987). The preparation and use of guidelines for the education of clients about the therapeutic process. Psychotherapy in Private Practice, 5(4), 71–83.
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