Documentation of necessity and progress are vital to our continued ability to help our clients. This requires specific description of the psychiatric condition and a complex understanding of progress that is unique to health care. Think in medical terms - progress is not a simple matter of continued improvement, like it is in other endeavors. Compare our work to keeping a person in respiratory distress alive. Interventions promote progress regardless of the severity of the condition or response in the patient. Medical progress is made when the patient is cured (rare), assessed, correctly understood/diagnosed, stabilized, prevented from relapsing, prevented from declining more than they have, recovered from an existing bad outcome, hospitalized for more intense treatment and in the worst case scenario given the best treatment possible until death (rare for us). Our interventions help clients make progress through continued stability at any severity of baseline, mitigation or prevention of symptom or substance abuse relapse, referral to more intense treatment and assistance in recovery from a bad outcome. Progress can be slow and is seldom sudden and earthshaking. Sometimes progress is improvement, yes. But more often it is standing still (maintaining stability) or taking two steps back instead of ten, and sometimes it is falling off the cliff then putting the pieces back together. Suggestions for documenting progress follow.
Opening – What is happening today, with an emphasis on the positive. If you are working on a problem that won’t seem to go away, it’s known as following through. Following through is very esteemed by readers. An intervention is positive when it is presented as identifying improvements to be made, for example. Anything can be phrased positively because you can put a problem in terms of how it is being addressed. You can present a client’s urge toward self harm positively in terms of a worse situation in the past or in terms of what you did to help identify it and act to help them cope or get appropriate inpatient care.
Analysis – Put what is happening now in context of the whole, emphasizing progress made over time. Mention the day’s goal and how it was either met or re-evaluated when surprises cropped up or exchanged for a more pressing goal. Mention the bigger goal that this is part of and pick a time frame that shows progress or work toward solutions. Mention the person centered goal as well and how today’s goal moves you toward it. You determine the time frames and contexts, so you are always able to put this in a positive manner as well. You are never truly stuck because you are always assessing, monitoring, linking to resources or treatment,introducing interventions or building on previous interventions.
Conclusion – How today leads to tomorrow or simplifies the goal or does something to help the client. Once again you choose the details and can direct the focus and attitude. Think of this as the main idea about progress you want the reader to come away with.
Advice to New Case Managers
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This interested me both as someone with a mental illness, and works with clients for whom "cure/total independent living" isn't realistically what I know will happen. Basically, when I get a client who previously would have torn up furniture/gone off on a staff person or another consumer when frustrated about communication, not being understood, instead go and slam the door to their room instead this while not a great behavior is better than in the past and thus progress. In fact, sometimes when you work with a particular consumer regularly you can fail to notice the progress made, but if you take the time and compare present behaviors to past in terms of severity, way they were handled, ect, positive process can be seen. In fact regularly working on providing positive feedback at the littlest signs of good stuff helps promote larger ones (ideally).
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