APS Case Documentation: Skill Building

Instructor-Led Training (blended with eLearning)

We create experiences that transform the heart, mind, and practice.

About the Academy & APSWI

The Academy is a project of San Diego State’s School of Social Work. Serving over 20,000 health and human services professionals annually, the Academy’s mission is to provide exceptional workforce development and learning experiences for the transformation of individuals, organizations and communities.

APSWI, or Adult Protective Services Workforce Innovations, is a training program of the Academy that provides innovative workforce development to APS professionals and their partners.

ACADEMY PROGRAMS

San Diego State University

Purpose of Land Acknowledgement

The purpose of a land acknowledgement is to recognize the relationship of Indigenous peoples to the land. It is multi-faceted in it’s meaning. It shows respect to the people of the land, to the land itself and to their relationship to one another. They are statements that recognize the dispossession from the land, the harm brought by colonial practices, beliefs and policies. They validate and recognize the continued presence of Indigenous peoples everywhere. Lastly, when offered in earnest and with sincerity, they are the first steps in reconciliation and healing.

​

For millennia, hundreds of Tribal nations have been a part of this land. This land has nourished, healed, protected, and embraced them for many generations in a relationship of balance and harmony.

​

As members of the Academy community, we acknowledge this legacy. We promote this balance and harmony. We find inspiration from this land and it’s original inhabitants of this Nation.

�Making a statement isn’t enough. It is important that we share ways people can take action to support Native American people and land back efforts. This can involve putting in time and effort to research and learn more about the indigenous communities of the lands you are on; returning artifacts and land to their appropriate tribal communities; working to protect and preserve the land, and much more. https://native-land.ca/

​

For more information and resources, see our Land Acknowledgement page at: https://theacademy.sdsu.edu/land-acknowledgement/

​

​

​

Land Acknowledgement

National Deliveries

Housekeeping & Course Overview

​

​

​

Housekeeping Items:

​

​

Review eLearning Concepts

Individual, Small, & Large Group Work

Self-Assessment

Case Scenarios & Videos

Course Overview

Learning Objectives

• Construct narratives that are clear, concise, and purposeful

​

• Summarize documentation standards of practice

​

• Determine the differences between subjective and objective documentation

​

• Identify case record requirements

​

Introductions and Connection�

SHARE

Your name, county/unit, and how long you’ve worked in APS

Favorite

part about documentation

Frustration with documentation

Fear

with documentation

SHARE ONE OF THE FOLLOWING:

eLearning Review

The Purpose of Documentation:

• Case history, Legal involvement, Accountability, Professionalism, Consistency, & Staffing/Funding

​

Objective vs Subjective:

• Facts vs. Perceptions

​

Person-Centered:

• Strengths, self-determination, experiences

​

Confidentiality:

• Guidelines, sharing and receiving

Self-Assessment

Key Concepts Questions

• Which of these concepts is a purpose of documentation?

​

• Which of these statements is objective?

​

• What APS value is emphasized in this piece of person-centered documentation?

​

• Per APS confidentiality regulations, which entities are typically given access to APS records?

Key Elements for Accurate Documentation

Documenting Indicators of Abuse, and Connecting to Findings

What are some significant indicators of abuse?

​

• Physical Indicators

​

• Behavioral Indicators

​

• Environmental Indicators

​

• Financial Indicators

Screening for Decision-Making Ability

• Foundational to APS work
• Important for safety, self-advocacy, resisting fraud, and self-determination
• Document decision-making ability in relation to choices and paths

​

• Decision-Making screening elements to document:
• Alertness, Orientation, Appreciation, Explanation
• Approved assessment tool or template
• Client’s expressed goals, wishes, concerns
• Collateral information

Documenting Risk Assessment

Let’s Practice! �

Review the case scenario in Handout: Noah J. Case Scenario

Identify what needs to be documented in terms of indicators of abuse, screening for decision-making ability, risk assessment

Report out key areas identified

Rat Feces Activity

What seems clear and concise?

​

What seems objective or subjective?

​

Review Handout and mark:

• True
• False
• Unknown

​

Subjective vs Objective

Objective:

• Explaining facts or conditions without distortion from personal feelings, prejudice, or interpretations based upon personal opinions and experiences.

​

​

Assessing for Physical Abuse

APSWI Training Video

*Content Warning:

Physical and Emotional Abuse

​

Subjective vs Objective

• The client became tearful when discussing the situation with her daughter.

​

• Lisa is likely homophobic.

​

• Lisa has some challenges with anger management.

• I observed 4 bruises on the client’s right upper arm, approximately 2 inches x ¾ inches in size, brownish-yellow in color.

​

• Goldie is too passive with Lisa.

​

• The client said she asked Lisa to clear her stuff out of her old bedroom.

​

​

​

​

​

​

​

​

Clear and Concise

Clothing:

• Focus on condition, cleanliness, appropriate for weather

​

Description of home:

• Focus safety and indicators of risk

​

Conversation & Statements:

• Focus on supporting factual information

​

Narratives

Using the video clip:

Person-Centered

Person-centered thinking:

• “focuses language, values, and actions towards respecting the views of the person and their loved ones. It emphasizes quality of life, well-being, and informed choice.” –National Center on Advancing Person-Centered Practices and Systems (NCAPPS)

​

How is this beneficial to:

• Clients
• Support systems/families
• APS programs

Person-Centered Specifics

• Language Needs
• Pronouns, Gender Identity, Sexual Orientation, Marital Status
• Person-first or Identity-first
• Goals
• Strengths
• Choices, Decisions, & Plans
• Other important physical, emotional, social and cultural aspects
• Additional information

Documenting during the Client ������������Documenting During Client interaction������������

Benefits

• Transparency & Trust
• Accuracy
• Efficiency
• Collaboration
• Demonstrates Professional practices

Challenges

• Perceived Disconnection
• Power differential
• Impact on Conversation Progression
• Confidentiality Concerns
• Technical Problems

​

Documenting during the Client �����������Considerations When Documenting Live������������

Etiquette & Best Practices

• Ask Permission
• Share the Why
• Positioning support transparency
• Pause to be present
• Invite corrections

​

​

Documentation Requirements

Case records should include:

• Required forms
• Written assessments
• Person-centered service plan
• Narrative of contacts
• Acceptance or refusal of services
• Case related documents
• Case closure summary
• Supervisory approvals

​

Anything else?

​

Timely Documentation

• Supports legal accuracy
• Captures details with fresh
• Ensures facts are captured accurately
• Reduces errors
• Mitigates risk
• Supports meeting mandates

​

​

Is this Complete?

Case Record Scavenger Hunt:

• In groups:
• Review case scenario
• Check off what applicable requirements should be included in case file
• Add anything else that should be included

​

• Report out

Workshop Summary & Questions

We covered:

• Documentation Standards of Practice
• Objective vs Subjective documentation
• Clear, concise, purposeful narratives
• Person-centered documentation
• Case record requirements

​

What questions do you have?

P-I-E

Reflect and note:

• Priceless piece of information
• What has been the most important piece of information to you today?

​

• Item to implement
• What is something you intend to implement from our time together today?

​

• Encouragement you received
• What is something that you already are doing and were encouraged to keep doing?

Evaluations

Your feedback is valuable!

• Please complete evaluations.

​

Thank you for taking time out to spend on your own professional development.

​

Thank you for what you do for our communities!

Thank You!

We envision a world where �the quality of life for individuals, organizations, and communities �is transformed into a healthier place.