12 Case Documentation
Revised: 08/03
12-02 Case Files
A physical case file shall be established for all applicants with the participant's name and Social Security Number affixed to the file folder. Upon entry into Eligible Status, dividers will be placed in the case file and all documents will be filed according to these divisions. The dividers shall be labeled to identify the information contained in the particular section. Under each divider, information will be filed chronologically with the most recent on top. The case file shall be set up as follows:
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12-02-03 Case File Security and Confidentiality
All DVR staff are responsible for case file security in the field offices. The Area Manager is responsible for instructing all employees' appropriate methods of insuring the participant's confidentiality and the security of these documents.
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12-02-04 Guest Access
AWARE is designed to promote confidentiality by limiting access to the electronic case record. Access is limited to the primary user, support users, backup users and managers related to the particular caseload. Guest Access is a procedure that allows time-limited access to other staff for the purposes of providing services or for review of potential transfers. For example, an assigned representative from DVR Psychological Services Unit may be granted access to a specific case for the purposes of a case consultation. This eliminates the need to provide the hard casefile or to make copies of specific items (except for medical/psychological records not contained within AWARE).
Guest Access can be provided for a period of up to six months. The primary user sets up the guest access and parameters. For levels of security and the methods for establishing Guest Access, see the AWAREHelp.
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12-02-05 AWARE Case Documentation
The AWARE case management system is designed to document participant information from referral through closure. The various datapages capture information relevant to the particular status or action associated with the datapage. Not all relevant information readily fits into headings provided for in the datapages and it is incumbent upon DVR staff to utilize the application documentation, comment sections and case notes to document:
all relevant historical information;
identify and address critical case questions;
interpret medical/psychological/vocational assessments;
justify decisions related to eligibility decisions, IPE development and case closure;
DVR efforts to facilitate informed participant choice, describing the extent to which participant exercised informed choice throughout the rehabilitation process.
Narrative sections located throughout the AWARE datapages should also be utilized to ensure that thorough documentation takes place.
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12-02-06 Case Notes
Case notes are an on-going record of significant events regarding participant activity as it relates to their rehabilitation process and includes analysis and synthesis of data relevant to the rehabilitation process. Any member of the rehabilitation team can enter documentation related to their interaction with the participant. Case notes become critical due to the fact that on-line reviews are an option for eligibility decisions, IPE and case closure. The following are guidelines related to case notes:
Case notes should not be changed or deleted once entered.
Case notes should be as long as necessary to convey the relevant information but should not report every detail of an interaction with the participant or verbatim conversations unless such detail is significant to documenting problems or rationale for decisions. The same applies to summarizing diagnostic, treatment, or progress reports.
Comments that may be considered derogatory should be substantiated by observed behavior or factual information.
Case notes pertain only to a particular participant's rehabilitation program. Critical comments about other agency personnel or procedures or philosophical discourses are inappropriate.
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