Chapter 7

Monitoring:The Contact/Activity Log andthe Interim orQuarterly ClientReview

Once the service plan is in place, the socialworker’s job is focused on seeing that the plannedactivities are carried out (process monitoring)and are moving the client and family towardmeeting their goals as they were designed to do(outcome monitoring). During this phase, youusually have two ongoing record-keeping tasks.First, you track some events, situations, andactivities while you are dealing with them, inorder to stay informed about what is happeningin the case. Second, you periodically documentthe significant events for your own use with theclient and family, and for use by your supervisorand colleagues. In accordance with these twoneeds, we introduce two tools in this chapter—a simple Contact/Activity Log for recordingongoing notes, and an Interim or Quarterly Cli-ent Review tool for information that is especiallysignificant and needs to be recorded in a moreformal way and kept.

The Social Work behind theRecordA Model for Excellence describes monitoring as“a mechanism for maintaining accountabilityand for providing necessary technical assistance”

(p. 89). In the course of describing this mecha-nism, it makes the following major points:

• There are two types of monitoring:those relevant to process and thoserelevant to outcome.

• Process monitoring is the action youtake to make sure that the activities inthe service plan are occurring accord-ing to plan, in a timely fashion, and atan acceptable level of quality.

• Outcome monitoring is the action youtake to assess whether the activitiesplanned (and correctly carried out) arehelping the client and family to reachtheir goals.

• Throughout the period of process andoutcome monitoring, you work withthe client and family to make adjust-ments to improve the quality of serviceactivities and to modify or replaceactivities to “correct the course”toward the goals of the client andfamily.

• As a social worker, you make adjust-ments directly, or through consultationwith colleagues, when problems arefound in DSS activities or services.

• You use counseling and technicalassistance to make adjustments inservices or activities being provided byinformal providers or other agencies.

The Contact/Activity Log

Why Is a Contact/Activity LogImportant?Most day-to-day monitoring focuses on activi-ties and their effect on the service plan and/orgoals. You notice and record the steps in gettinga service, the quality of services obtained, anyproblems that arise, the feelings of the client and

85

86 Social Worker’s Guide

A Guide to Record Keeping in Adult Services

family about them, and any changes they makein their lives. However, in the course of workingwith any given client and family toward meetingtheir goals, many tasks, concerns, and incidentsarise that require your short-term attention andaction.

Say, for example, that you tell a client youwill pick up his insulin this month, because hisusual arrangement for getting it is no longerworking, or suppose that there is a conflictbetween a client’s in-home aide and one of hisfamily members. You want to record the day-to-day details, both as a reminder to yourself and asinformation for a colleague if you were unex-pectedly unable to come to work. However, onlya summary of events and activities needs to berecorded as part of the Interim or QuarterlyClient Review after the issue is resolved.

Take, for example, the case of a conflictbetween a family member and an in-home aide.The Interim or Quarterly Client Review in thecase record might need a summarizing notationsuch as: “Mr. Bennett’s daughter, Sarah Sullivan,complained to SW that Ms. Lloyd, in-home aide,was doing nothing but watching soap operasduring her visits. Met with both individually toreview the in-home aide services plan. Mrs.Sullivan agreed to check whether the listed taskswere being done for two weeks following hercomplaint and to call if she still believed Ms.Lloyd was neglecting her written duties. Therehave been no additional complaints.” Some mayprefer a briefer form such as “Conflict betweenclient’s aide and daughter over aide’s job perfor-mance. Resolved by reviewing in-home aideservice plan with both parties.”

Although either of these notes is an adequatesummary for the client’s record, the same socialworker would probably have made a longerseries of notes in the course of this conflict.These notes, recorded on the Contact/ActivityLog, might include the following: 2/15 tc from Sarah Sullivan—argument

with father’s (John E. Bennett) in-home aide. Accused aide of doing

“nothing but watching soap operas.”Won’t meet with Ms. Lloyd and SWtogether—office appt. Tues. 2/19 at12:15 noon. (Works near office.) Toldher I would be talking to the aide.

2/15 tc from Bonita Lloyd, in-home aide.Mrs. Sullivan asked her to removestains from carpet—told her carpetcleaning not her job. Told her of appt.with Mrs. Sullivan. Asked to talk withher when I came to bring Mr. B. hisnew quad cane.

2/18 hv to Mr. Bennett. Trying to walkmore, glad to get new cane. Mr. B.does not want to get involved indisagreement, but willing for me totalk to daughter and aide. Talked toMs. Lloyd. Reviewed in-home aideagreement. Supported refusal to cleancarpet, but talked about ways to say“no” without being confrontational.

2/19 ov with Mrs. Sullivan. Reviewed in-home aide services plan and nature ofaide services. Gave her a copy ofplan—told her to call if she felt thatany of the scheduled aide duties werenot being performed. Suggested one-time “deep cleaning” of her father’shouse through local house cleaningservice. Note: Call Ms. Lloyd and Mrs.Sullivan later in month.

2/27 Called Ms. Lloyd. No more conflictswith Mrs. Sullivan. Few contacts coolbut not antagonistic.

2/28 Called Mrs. Sullivan. Reports noproblems with aide services.

This example shows how the Contact/Activ-ity Log and Interim or Quarterly Client Revieware complimentary.

Using the Contact/Activity LogThe Contact/Activity Log is a simple, straight-forward tool on which you can record phonecalls, visits, and other activities you undertakewith and on behalf of the client and family. It is

Chapter 7 87

Monitoring

used between the creation of the initial serviceplan and the first quarterly review, and betweensuccessive quarterly reviews.

In most agencies, workers have kept day-to-day notes on service implementation and moni-toring in their “case notes,” “narrative,” or “dic-tation.” These notes have usually gone into theclient’s record permanently. The difficulty withrelying on these notes later is that they do notusually distinguish between events that weresignificant over the long-term course of workwith the client and those which were only impor-tant during the day-to-day management of thecase. This is why we recommend that you trans-fer significant events to the Interim or QuarterlyClient Review. If this is done, the day-to-daynotes do not have to be presented in any particu-lar format or produced in any special way, andthey can probably be thrown away at the end ofthe quarter unless needed for court or auditingpurposes. You will want to consult with yoursupervisor about the proper policies and proce-dures to follow to remain consistent with audit-ing expectations. It may be possible, for ex-ample, to record all vital dates of contact on theInterim or Quarterly Client Review. Regardlessof policy considerations, you may want to keepnotes longer when you first start using thissystem, until you feel comfortable that you areadequately summarizing the quarter’s signifi-cant events and will not need to refer to themagain.

Unlike other tools presented in this guide,we are not recommending that you use the Con-tact/Activity Log instead of any other tool youmight have. Workers do not have to be uniformin the tool they use to record notes about the day-to-day management of a case. The tool is prima-rily for your use. A pad of notepaper or a com-puter word-processing file will serve the samepurpose. The only consideration for how youkeep these notes is that they be accessible to yoursupervisor or a colleague so that someone knowswhere to look to be brought up to date on yourcase quickly. Some workers who are currently

using this format clip the current log to the insidefront cover of the client’s record so all theirinformation is together.

The notes on the Contact/Activity Log canbe handwritten with strike-throughs or erasuresas long as your colleagues can read them whennecessary. This also means that the writing styleand level of detail you keep is largely a matter ofpersonal style and need. Because these notes donot have to be formal in either content or produc-tion, you should be able to write them on the spotin a few minutes and not get behind.

The example on page 88 shows the first twoweeks of notes following the creation of theservice plan for Mrs. Johnson and her family. Itdoes not show all of the notes that would be madeduring the first quarter, but it does illustratesome of the activities associated with imple-menting and monitoring that plan. It shows that,even in writing up the notes, the main focus is onwhat changes have taken place relevant to thegoals of the client and family.

Although most social workers today, withgood reason, avoid the “and then I said . . . , andthen she said . . .” style of notes, sometimes anotation of how the client or family member saidsomething or how they responded to a sugges-tion helps convey their emotional response—fears, beliefs, hopes, and preferences—moreclearly than a lot of analytical language. Anexample of this is found in the entry for the homevisit on 2/20/95. At that time Mrs. Johnsonreported that her sister said “nobody from thisside of town” goes to the senior center.

The social worker looks into this possibilityand finds that this correctly reflects a real skewin the senior center’s clientele. She further learnsthat Mrs. Johnson’s minister does not knowanyone who attends the center. At this point, thesocial worker and Mrs. Johnson decide that thismay not be a good activity to meet her goal offeeling more positive. For another client, goingto the senior center with friends and working tohelp expand the diversity of its clientele mightbe a fulfilling activity.

ClientCase #Id #Contact/Activity Log

Date Contact or Activity Results of Contact/Activity

DSS-6222 (8-1-94)

Mary F. Johnson95-10019

18937485368

2/9/95

2/9/95

2/10/95

2/10/95

2/17/95

2/20/95

2/20/95

2/20/95

Bob Griffith, Services forthe Blind

tc to Louise Sullivan,Kudzu Hospice

tc from Mrs. J.

Cecilia Rossi,Transportation Worker

tc from Barbara Jenkins,Council on Aging

Home visit to Mrs. J.

tc to Mr. Johnson (son)

tc to Rev. Abernathy

Will send voucher for eye exam to Mrs. J. by mail.

Briefed me re: grief support. Will send brochures on bereavment supportgroup—also widows’ support group run by the Kudzu All-FaithCouncil. I will take them to Mrs. J. and answer questions.

Eye appointment with Dr. Elkins set for 3/10/95. She has new heatingpad and a lightweight flashlight/lantern to use on the stairs. Says thatson will get new stove knobs next weekend. Stove knobs still markedwith electrical tape—seems to help.

Will arrange transportation for Mrs. J. to eye exam

Today Mrs. J. scheduled to visit senior center, but waved van on. Willcall Barbara to reschedule after hv to Mrs. J.

Introduced Mrs. J. to in-home aide, Mrs. Gooch. Reviewed aide’sschedule and activities. Gave Mrs. J. brochures. She said her son wouldread them to her as reading is getting too hard for her because of hervision. I asked her about not going to the senior center. She said she hadcalled her sister, Dot (one of her weekly social calls) to try to make up fortheir past falling out. In the course of their conversation Dot told herthat nobody from their side of town went to that center. Told her I wouldfind out more about the center before our counseling visit next week.Discussed with Mrs. J. several possible physicians and gave her phonenumber to call for an appointment. She said she felt comfortable doingthis herself.

Reported Mrs. J. has not left the stove on this week. All other safetyhazards fixed except permanent stair lighting. Reports his mother inbetter spirits than he has seen her for some time. Also reports Rev.Abernathy (Mrs. J’s minister) happy to get church more involved .I asked whether any of his congregation goes to Sr.Ctr. He says he doesn’tknow any. He said he had spoken to her son and intended to ask Mrs. J.if she would like Tues. prayer circle to meet at her house next week.

Chapter 7 89

Monitoring

The Interim orQuarterly ClientReview

Why Is the Interim or QuarterlyClient Review Important?You’ll remember that A Model for Excellencedescribes two types of monitoring: process andoutcome. You can document much of your pro-cess monitoring using the log and the serviceplan; however, the quarterly review is your toolfor systematically recording outcomes. As such,it documents both an event (the quarterly visitwith the client) and the essential changes in theclient’s and family’s circumstances over thereview period. This is the time for checking theprogress of your client/family/social workerteam. Are the activities meeting the goals? Doesyour team need to plan different activities? Doesthe team need to set new goals to address remain-ing problems? What has to happen to maintainthe progress your team has made? This tool isdesigned to be used at least quarterly. However,when drastic changes occur in the client’s life,you may want to perform this review, or even afull reassessment, at that time.

Using the Interim or QuarterlyClient Review ToolThe Interim or Quarterly Client Review tool hasthree sections—orientation to the review, whichgives you space to document your sources ofinformation; a review of functional domains,which may include important process elements;and the progress on goals, which is very out-come-oriented. Let’s look at each part sepa-rately.

Orientation to the ReviewThe tool begins with an orientation to the review,which includes space to record identifying data,sources of information, and major changes in the

Other Day-to-DayDocumentationThe notes in the Contact/Activity Log are not thesocial worker’s only documentation for the ac-tivities shown in the example. For instance, sheupdated the face sheet to show the names andphone numbers of the aide, the ophthalmologist,and Mrs. Johnson’s minister. She also updatedthe service plan as activities were completed.For example, on 2/9, after arranging for the eye-exam voucher, the social worker recorded thatdate in the “Activity Completed” column.

After Mrs. Johnson’s call on 2/10, she re-corded that date for what had already been doneto correct hazards in her home. This includedgetting a new heating pad and arranging fortemporary lighting for the stairs. Because rugswere still not secure and the stove knob had notyet been replaced, it was not possible to mark theentire activity as completed. In the example, thesocial worker struck through and dated the parts ofactivities as they were completed, but you mayprefer to record this information only in your log.

During this same call, Mrs. Johnson reportedthat she had made an appointment with theophthalmologist. This activity under goal 2C isthen identified as accomplished. The socialworker also used the service plan to record thedecision for Mrs. Johnson not to visit the seniorcenter (noting that this planned activity waswithdrawn as of 2/14). Later, when Mrs. Johnsonlearned that she needed her cataracts removed,the social worker worked with Mrs. Johnson andfamily in adding new activities to the serviceplan, including transportation and additional aideservices on a short-term basis. These updates areincluded on the sample at the end of this chapter,which shows how the service plan for Mrs.Johnson looked after the first quarterly review.

90 Social Worker’s Guide

A Guide to Record Keeping in Adult Services

life of the client or family. After filling out theidentifying information, you can describe howthe review was performed, using a pair of check-lists that ask where the review was conductedand who contributed information during thereview period.

In the first checklist you indicate where yourreview with the client and family was conducted(e.g., client’s home, hospital, nursing home/domiciliary care). The social worker in the ex-ample has checked client’s home and telephonebecause her review included information gath-ered from a visit in the client’s home as well asinformation from other sources contacted bytelephone at the time of the review and through-out the preceding quarter.

Using the second checklist, the social workernotes her sources for information on the tool. Hersource during the visit was the client; but she alsolists the son (other family), the ophthalmologist,the in-home aide, and the home health nurse,because all of them have given her informationreflected on this tool. This social worker has notincluded contacts who gave her less vital infor-mation such as her contact at the Council onAging and Mrs. Johnson’s minister. This is ajudgment call, and not all social workers willmake exactly the same decisions about whom toidentify using the checklist.

After describing how the review was con-ducted, you are then given space to record anymajor changes or events since the last reviewthat have “substantial” impact on the life of theclient and family or their need for services. Youmight record here a change of environment, suchas placement in a facility or moving into a newhome; a serious health problem such as a stroke,heart attack, or automobile accident; or a changein financial status, such as selling a piece of landor cashing a life insurance policy.

In the example, the social worker has re-corded Mrs. Johnson’s cataract surgery as anevent that had a substantial impact because itaffected Mrs. Johnson’s functioning in severaldomains and influenced several of her goals.

The social worker also uses the space to give abrief statement of how the surgery affected her.For other clients whose vision had not deterio-rated as much as Mrs. Johnson’s, or whosevision was not so central to the positive changesthey hoped to achieve (their Checklist forChange), information about the surgery mighthave been recorded instead under the physicalhealth domain in the next section of the tool. Ifthere are such changes as a new address ordifference in family composition, you will alsowant to update the Face Sheet.

Review of the Functional DomainsThis second section of the tool is a sort of mini-reassessment, structured in terms of the six func-tional domains. It is a place to note changes in anyor all of them. Using what you have learned overthe quarter and from your review, you can use thespace provided in the second section to summarizeany important findings and impressions that mayhelp when you next think about the goals and whatchanges in the service plan might be necessary.This may include new problems, worsening con-ditions, improvements, and new resources aswell as accomplishments. In addition to spacefor each functional domain, you also have roomto summarize any other significant events, con-tacts, or activities that occurred since the lastreview. You probably will want to note the datefor each important happening you mention. Analternative to recording this information is toattach and highlight relevant sections of yourContact/Activity Log.

The example at the end of the chapter showshow a review of the functional domains couldhelp Mrs. Johnson’s social worker in severalways. It documents improvements in Mrs.Johnson’s social functioning and environmentthat support conclusions about her goals beingmet. It identifies a newly diagnosed health prob-lem (high blood pressure), and two types ofmedication Mrs. Johnson had not been takingpreviously. Perhaps most importantly, it showsthe changes in her ADLs and IADLs—more

Chapter 7 91

Monitoring

activities that she attempts, but worse arthritis—and the emotional impact of seeing that shecannot keep her house as clean as she wants. Thissets the stage for new goals that can probably bemet by the same in-home aide. It also indicatesthat Mrs. Johnson’s economic situation haschanged with her need to purchase the medica-tion, the cost of which is not covered by Medi-care. The client/family/social worker team tacklethis with an addition to the service plan. Thesocial worker in our example cross-referencedthis by writing “(see service plan).”

The final space in the functional domainportion of the tool is for summarizing otherevents in the quarter that did not fit well withina domain. In some counties, a list of the dates ofcontacts (from your log) with a brief summary ofoverall events will constitute adequate docu-mentation of daily activities for monitoring pur-poses. However, if your county asks you toattach your contact log to the quarterly, it isunnecessary to duplicate information here. Still,you may want to use this space to put a “red flag”on any event with particularly urgent conse-quences for the client and family.

GoalsThe tool concludes with a section to recordprogress notes on goals. The section is set upfirst to identify each goal with the number fromthe service plan or by recording some briefnotation to remind you of it. You may want to doboth. You do not need to write the full goal. In theexample, below and on the following page, thesocial worker has simply written “stove” by goal1A, which is sufficient to remind her that thegoal was “stove turned off consistently while notbeing used for one month.” Notice that she listsgoals for the same item for change separatelywhere the progress and disposition are unrelated(e.g., for goals 1A and 1B). In other instances,where disposition is the same, and the progressnotes are related, she combines goals (e.g., forgoals 2A and 2B, medical care).

For each goal or set of goals, there is a placeto note progress or setbacks and then to checkwhether the client/family/social worker teamhas met the goal and can stop working on it, willcontinue as is since the goal is being met, is stillworking toward it, needs to try a new strategy, orshould revise the goal.

You can use the space labeled “Progress” tonote the current state of the client and family inrelation to the goal—how a goal was met, whatpart of the goal remains unmet, what factorsinterfered with meeting it, why it needs to berevised, or to identify some other approach tomeeting it. In short, these notes support the dis-position checklist. Most of these possibilities aredemonstrated in the case example.

Three of the six goals listed on the exampleare marked “goal met/discontinue,” and the otherthree have very straightforward explanations.The goals of getting a physical exam and amechanism for regular care (2A and 2B) areexplained by a notation naming her new generalpractitioner. Similarly, the goal of identifyingand correcting her vision problem (2C) was metby cataract surgery.

The note for goal 1A gives a little more detailbecause there had been some ambiguity aboutthe reason for Mrs. Johnson leaving the stove on.Because the problem appears to have been rem-edied by correcting her vision, the client/family/social worker team feel free to discontinue thegoal. If, on the other hand, Mrs. Johnson had mether goal by using memory training and behaviormodification techniques, they might have de-cided to “continue working on the goal” or“revise the goal” to reinforce this behavior for alonger time and make sure a permanent changehad been achieved. Goal 1B, fixing or removinghazards from the home, was finally met by theend of the quarter. Mrs. Johnson’s son did tackdown her throw rugs and replaced the knob onthe stove.

Three of the goals required more work, or atleast some ongoing review. On the goals related

92 Social Worker’s Guide

A Guide to Record Keeping in Adult Services

to Mrs. Johnson’s outlook on life (4A and 4C),the planned activities were carried out and therewas some indication that she was benefiting fromthem, but more time was needed to achieve thegoals. Goal 4B, increasing Mrs. Johnson’s socialcontacts, is revised so that it becomes a goal to bemaintained instead of a goal to be achieved. BothMrs. Johnson and the social worker know thatreaching out to people is a new habit that must bepracticed before it becomes second nature.

Goals 3A and 3B, involving Mrs. Johnson’sability to bathe and wash her hair, must berevised to reflect changes in ADLs. Notice howthe social worker uses the relevant domain in theprevious section of the tool to record additionalnotes about changes to this goal.

You can use the disposition “other” for caseswhere the checklist items don’t fit. One examplewhere this disposition might be used is when aclient wishes to stop working toward a goal thathas not yet been met. However, this label couldbe used for any unusual dispositions.

Because there are more goals than space onthe Interim or Quarterly Review tool, the socialworker copied the back of the tool, recordedsome identifying information about Mrs.Johnson, and continued recording goals, progress,and disposition. You could do this if you needmore space, or you could use a blank sheet ofpaper. She also signed this last page when shecompleted the review.

The final step in the review process, otherthan signing the tool, is updating the service planbased on what is known about any significantfunctional changes and the progress on goals. Arevised plan for Mrs. Johnson, for example,might reflect a goal and strategy to address theincreased concern about her finances. Depend-ing on the extent of the changes made to theservice plan, the social worker may mark themon the existing tool, dating and initialing changes,or she may choose to start with a fresh page,copying over remaining goals and adding new ormodified ones. The social worker in our samplecase decided to mark them on the existing tool,

adding an additional page. Her revisions areshown on the last pages of this chapter.

Frequently Asked Questions

Question: What if there are significant things inmy contact log that my colleagues and supervi-sor should know about, but they don’t seem to fitanywhere on the Interim or Quarterly ClientReview?Answer: You are right that it is important to

include this information on the quar-terly review. If it is a major event youmay want to record it in the openingsection (events with substantial im-pact). Otherwise, if it does not fit wellunder any of the six functional do-mains or in the progress notes, you canuse the additional space provided atthe end of section two of the tool forsummarizing any other significantevents, contacts, or activities. Attachlog sheets or additional notes if neces-sary. Remember that the tool is in-tended to work well for you and yourclients and their families.

Question: How often do I need to update the facesheet and the service plan?Answer: Updating documents is a little like

keeping the house straightened up. Youcan take an extra minute to put thingsaway as you use them, or you can take afew hours putting everything away whenthings have accumulated. It is yourchoice, but there are some rewards fordoing it on the spot. This should justmean jotting the new address or phonenumber on the face sheet as you learn it,or writing a date on the service plan asyou learn that an activity has been com-pleted, or that a goal has been met.

At least once a quarter (preferably atthe time of the quarterly review whenyou need to update the service plan withnew goals and activities), you will take a

Chapter 7 93

Monitoring

look at these documents and see if theyare still readable or if you need to fill outa new copy of the tool. (Many socialworkers prefer to start a new service plantool after the annual reassessment.)

Key Points

• There are two types of monitoring:process and outcome.

• Although there is overlap between theactivities, process monitoring is gener-ally documented on the Contact/Activity Log, while outcome monitor-ing is documented on the Interim orQuarterly Client Review.

• Information learned in the course ofmonitoring will often require updatingthe face sheet and the service plan.

• The style of entries in the contact/activity log and the tool on which theyare written are at the discretion of theindividual social worker. Of course,you want to be sure that they arereadable by your supervisor andcolleagues.

• The content of the contact/activity logfocuses on the functional impact ofevents on the client and family—howactivities and events affect the plannedservices and attainment of the goals forthe client and family.

• An excellent quarterly review providesall information the client/family/socialworker team needs to revise and addnew goals, and to plan continued andadditional activities to meet them.

Though Mrs. J. isn’t entirely happy w/housekeeping, house is cleanerand safety hazards have been fixed.

Better rapport w/sister. Son & wife heartened by client’s progress—have been more willingto be helpful. Client is reestablishing friendships at church—some members visit her andtake her to church activities. Also making friends in widows’ support group.

New meds for high blood pressure, diagnosed by new M.D., who also suggested changein diet. Mrs. J. not so happy about learning to cook differently. Also meds for arthritis pain mgmt. Noins./Medicare coverage for cost of meds., which puts her at least $20 over current budget.

Mrs. J. is doing more housework and self-care since surgery, but arthritis is worse.

At first very happy after surgery, but now more aware of problems housekeeping,so sad and frustrated. “I see all the things I want to fix up, but I just can’t do it like I used to.” Likeswidows’ support group, finds it helpful to talk to “people who know what I been through.”

Mary F. Johnson

95-10019 189374853685/5/95

✔

✔ Son

✔

✔ Dr. Elkins, ophthalmologistDana Gifford, RN (home health)

✔

✔

Cataract surgery—vision restored. Physical recovery very good. Some increased signs of depression—may be related to increased awareness that she is unable to keep her house as she wants it.

Mrs. J. and family concerned about cost of two extra medications.

1A, stove

Eyesight seems to have been cause. Mrs.J. now turning off stove consistently. Sonno longer worried about this.

✔

1B, hazards

Hazards fixed, permanent light in stairs.✔

2A&Bmedicalcare

Dr. May Shepard is Mrs. J.’s new M.D.high bp diagnosed, new meds. and diet.New Rx for arthritis, not as helpful ashoped. Prescriptions make financialproblems, though.

✔ See service plan updatesabout finances

2 C, vision

Successful cataract surgery.

✔

See additional goals.

Plan for sr. ctr. visit withdrawn from service plan because Mrs. J. felt that thepeople who go there wouldn't share many of her interests and background.

Mary F. Johnson18937485368Q Rev. 5/5/95

3A&B,personal care

Aide services meeting goals. Continuesto need some help with self-care.

✔

4C, betteroutlook

Six counseling visits. Throughreminiscence about good and bad times, she hascome to terms w/loss (doesn’t always tear up).Thinks about what she wants to do now forherself. Enjoys widows’ group, will continuewith them. Meetings w/SW as needed.

Self-rating from 7 good days first monthto 15 this last month. GDS from 12 to 9,but she says she is sad that she can’tphysically do everything she would like.

4C socialcontacts

✔

She is pleased with progress,though says sometimes when she is hurting shejust doesn’t want to talk to anyone. Weeklycontact w/church members and widows group,makes her phone call, son says wife is pleased,relationship better with sister.

✔

Virginia WhiteSee new goal on service plan.

✔4A, talk abouthusband w/outcrying

Client: __________________________________ Initial __Update __Quarterly __Reassessment

Case #ID #Date initiated

GoalMet

Person/Agency Responsible

TargetDate

ActivityDone

Checklist for Change(Problem/Need) Activities/ServicesGoal

Adult and Family Service Plan(Use additional sheets as necessary.)

DSS-6221 (8-1-94)

Mary Foster JohnsonX

a. Mark stove’s off positionwith tape ............................. SW, Mr. J.

b. Mrs. J. will turn off stove ... Mrs. Jc. Mr. J. will monitor stove

to reassure himself ............... Mr. J

a. Rugs tacked downsecurely, new heatingpad purchased, stove knobreplaced, temporarylighting for stairs ................ J. Family

b. Find source of help forpermanent lighting onstairs (COA, church,Boy Scouts?) ........................ J. Family & SW

1. Mrs. J. is not safe at home:stove is not turned off; problemswith heating pad, stove knobmissing, dark stairs, slipperyrugs

1A. The stove will be consistentlyoff when not in use for 1month

1B. Identified hazards in Mrs.J.’s home will be fixed orremoved within 6 weeks.

2A. Mrs. J. will have a physicalexam within 6 weeks.

2B. Mrs. J. will have a plan forroutine preventive medical care

2C. Mrs. J. and family will knowcauses of cloudy vision withinthe quarter and whether/whattreatment is possible

2. Mrs. J. lacks current medicalcare: her arthritis, her cloudyvision, her forgetfulness havenot been evaluated recently

3/22/95 a. Identify new physician,make appointment, andhave physical ....................... Mrs. J

a. Get voucher for eye examfrom Services for Blind ....... SW

b. Make appt. w/eye doctor,have eyes checked ................ Mrs. J

c. Arrange transportation toappointments ...................... SW or J. Family

2/6/951893748536895-10019

3/22

3/6/95

2/9

2/6

tc w/son2/20,

3/20, o.k. 5/5

5/5

5/5

2/15, per tc;appt. 2/28

5/5

This page and the next show what might

have happened to the original service

plan over the first quarter. Colored ink for

the changes would make them more obvi-

ous. The third page shows updated items

for change and new goals.

appt. 3/6 2/10

2/10, partial

remaining itemsfixed, 3/10, per

tc w/Mrs. J.

2/10

Social Worker

Date

Client

Date

Other (optional)

Date

Checklist for Change(Problem/Need)

Person/Agency Responsible

Activities/ServicesGoalTargetDate

ActivityDone

GoalMet

DSS-6221 (8-1-94)

3. Mrs. J. cannot bathe and washhair as often as she wishes

3A. Mrs. J.’s hair will be washedtwice a week (ongoing)

3B. Mrs. J. will have a bath atleast every other day (ongoing)

2/24 a. 1hour of in-home aideservices 2x/week (seein-home service agreement) (short-term assistance) ...... DSS, SW

b. Check pain control, rehabpossibilities with newphysician (see item 2)............ Mrs. J.

4. Mrs. J. is sad about her life andshows some signs of depression onthe GDS

4A. Mrs. J. will be able to talkabout her husband and hisdeath without always crying orhaving the feeling that lifewill never be good again.

4B. Mrs. J. will talk to someoneother than her son and hisfamily at least twice a week

4C. Mrs. J. will feel more positiveabout her life, as measured byher own daily rating and theGeriatric Depression Scale

5/8/95 a. Counseling visit 2x/month for 3 months to talk about grief issues ......................... SW

b. Read literature aboutbereavement group and SW to get this,consider joining................... Mrs. J. will read

a. Talk to minister re: homevisits, transportation tochurch ................................. son, family

b. Phone one friend or relative (besides family) eachweek ................................... Mrs. J.

c. Trial visit to senior center Council on Agingw/van pick-up .................... SWwill arrange

a. Mrs. J. will mark hercalendar to indicate dayswhen she feels better.GDS at next review. .......... Mrs. J., SW

Deferred ItemsMrs. J.’s shaky finances

5/8

5/8

withdrawn,2/20

2/17

2/17

2/28

meetings PRNafter 5/5

2/20

5/5 ongoing

ongoing

5/5

Virginia White

2/6/95

Mary F. Johnson

2/6/95

Robert Johnson

2/6/95

Client: __________________________________ Initial __Update __Quarterly __Reassessment

Case #ID #Date initiated

GoalMet

Person/Agency Responsible

TargetDate

ActivityDone

Checklist for Change(Problem/Need) Activities/ServicesGoal

Adult and Family Service Plan(Use additional sheets as necessary.)

DSS-6221 (8-1-94)

4/30/95

Update4/7/954. Outlook on life

4 A& B. Manageable griefabout husband/more contactwith others

8/6/95 a. Widows’ support group Kudzu All-FaithCouncil

begun4/9/95;ongoing

Update5/5/955. Mrs. J.’s monthly expenses

exceed her income by $20.00because of new medications

5. Before the end of the year,Mrs. J. will have enoughincome to meet her regularexpenses

a. Meet w/son and finan-cial planner at KudzuWomen’s Center

b. Contact representativeof SHIIP programthrough Sr. Ctr.

SW to providephone nos. forboth; Mrs. J.will call

5/9/95

Mary Foster JohnsonX

Update

3/15/932. Cloudy vision, continued 2C. know cause of cloudy vision,

and treat if possiblea. Transportation to and

from 2 outpatientsurgeries .............................. church members

b. Stay overnight w/Mrs. J.after each surgery ...............dau.-in-law, grand-

daughterc. Postsurgical home visits ......Kudzu Home Healthd. Temporary increase in

in-home aide hours(see in-home aide plan) .......DSS/Mrs. Gooch

4/1 &4/19/95

4/1 &4/19

4/23

4/1 to4/23/95

4/23

12/30/95

3/15/951893748536895-10019