e1 estanislao towards the development case notes

7/31/2019 E1 Estanislao Towards the Development CASE NOTES

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Towards the Development of the

Case Notes Assessment Scale

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Flow of Paper Presentation

1. Background of the Study and Review of

Related Literature

2. Conceptual Framework

3. Statement of the Problem

4. Method Design, Participants, Instrument,

Data Gathering Procedures and Analyses

5. Results and Discussion

6. References

7. Appendix


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Background of the Study and Review ofRelated Literature

The Guidance and Counseling Act of 2004

(R.A. No. 9258), seeks to professionalize thepractice of guidance and counseling in the

Philippines.

International Association of Counseling

Services, Inc., professional ethical practice

forms the cornerstone of the counselingservice. Systematic case records (Kiracofe, Donn,Grant, Podolnick & Bingham, 1994).


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Call for Accountability from counseling professionals

who are expected to accurately document what hastranspired during their counseling session or

therapeutic hour in the form of case or progress notes

(Cameron & Turtle-Song, 2002).Case notes, which are part of the student records and

kept in the Counseling Office, serve as tools in

monitoring the clients progress in counseling and indeveloping the counselors case conceptualization

and treatment planning skills.

These records also serve as reference for anothercounselor or specialist who may handle the same

client in an emergency case through referral

procedures (Estanislao, 2010).


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Prieto and Scheel (2002) presented the

STIPS format for organizing case notes

that could increase the counselor trainees

case conceptualization skills. It consists offive major sections, such as, Documenting

clients current Signs and Symptoms,

Topics discussed in Counseling,Counseling Interventions used, Clients

Progress and Counselors Continuing Plan

for Treatment, and Special Issues ofImportance regarding clients.


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Travers (2002) emphasized the need ofwriting high-quality case notes, which can

be time-consuming.These notes serve as a

record for other counselors who may meetwith the same client being handled in an

emergency situation or when the client

transacts to another counselor. Case notes

are for supervision and court purposes. A

state or federal court of law can subpoenaclient files if legal action is taken against

you or your client.


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Cameron and Turtle-Song (2002) reported anumber of models that enable counselors to

identify, prioritize and track client problems so that

they can be attended in a timely and systematic

manner. They also provided an on-going

assessment of both the clients progress and

counselors treatment interventions. Components of

these models include the Data, Assessment and Plan

(DAP), Individual Educational Programs (IEP),

Functional Outcomes Reporting (FOR), and

narrative notes, all are variations of the originalSubjective, Objective, Assessment and Plan

(SOAP) note format.


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Conceptual Framework

Cameron and Turtle-Song's (2002)

Subjective, Objective, Assessment and Plan

(SOAP) Note Format Standards, as

described in the Problem-Oriented MedicalRecords (POMR) Model. (a) Clinical

Assessment (b) Problem List (c) Treatment

Plan (d) Progress Case NotesRULES and SAMPLES


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Statement of the ProblemTo initially develop an instrument that will assess the

current case documentation process and outcome of

counseling professionals in accordance to prescribednote format and standards.

1. What are the factors or subscales that will measure the

counseling professionals' current case documentationprocess and outcome with reference to a prescribed way

of writing case notes?

2. Is the Case Notes Assessment Scale a reliable

instrument in measuring the counseling professionals'current case documentation process and outcome?


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Hypotheses

1. There are factors or subscales that will measure

the counseling professionals' current case

documentation process and outcome with

reference to a prescribed way of writing case

notes.

2. The Case Notes Assessment Scale is a reliable

instrument in measuring the counseling

professionals' current case documentationprocess and outcome.


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Method

This study employed the following 10 steps in test

development.1. Search for Content Domain

In the search for the content domains, Cameron

and Turtle-Song's (2002) Subjective, Objective,Assessment and Plan (SOAP) Note Format

Standards, as described in the Problem-Oriented

Medical Records (POMR) Model wasconsidered, as discussed earlier.


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2. Item Writing and Review

Based from the literature, thirty one (31) items under three (3)

factors were constructed and the verbal frequency scale was used. The

items were reviewed by three (3) experts from the fields of Counseling

Psychology and Psychological Assessment for clarity and culture

contextualization. Some items were deleted, some were revised andsome were added. After the review of items, the pre try-out form was

constructed.

3. Development of the Pre Try-out Form

The instrument used for this study was the Case Notes

Assessment Scale (CNAS). It contained a 31-item, 5-point Likert type

self-report instrument following Cameron and Turtle-Song's (2002)

Subjective, Objective, Assessment and Plan (SOAP) Note Format

Standards that focuses on case documentation process and outcome.

The participants were asked to rate their degree of agreement ordisagreement to each of the statements using a scale from 5 as

Strongly Agree to 1 as Strongly Disagree.


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4. First Trial Run

Sevilla, Ochave, Punsalan, Regala, and Uriarte (1992)mentioned that at this stage, the language suitability of the items and

ease in following test directions from the point of view of the

respondents should be determined. They also suggested that the average

length of time to finish the test and other problems relevant to test taking

should be determined during this phase. In this study, three (3)

respondents were asked to identify the items which were not clearly

understood after taking the pretest form.

.

5. Development of the Main Try-out FormThe comments made on the pre try-out form were considered

and the main try-out form was developed. The main try-out form was

now consisted of 30 items. The CNAS is an instrument that measures the

current case documentation process and outcome of counseling

professionals based on prescribed standards. Again, the participants were

asked to rate their degree of agreement or disagreement for each of the

statements using a scale from 5 as Strongly Agree to 1 as Strongly

Disagree.


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6. Final Test AdministrationThe administration of the main try-out form was

done to initially establish the psychometric

properties of the CNAS. The instruments werefielded to a total number of 151 participants

during the seminar-workshops that I conducted

within the period of one year from May 2010 toMay 2011. Sampling design was purposive

7. Evaluation of Test Validity

Factor analysis was primarily used to validate theCNAS, Exploratory factor analysis was done

using several factor solutions.


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8. Evaluation of Test Reliability

The reliability of the Case Notes Assessment Scale

(CNAS) was determined using the Cronbachs Coefficient

Alpha formula. This method examines the internal

consistency of the CNAS through an analysis of theindividual test items. The inventory was administered once to

151 participants but only 140 records were determined as

valid for the main try-out.

9. Development of the Final FormIn the final form, one item was deleted and the rest 30

items were accepted in the process. There were three factors

extracted in the Principal Components Analysis namely,

Record

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10. Plan on Developing Norms


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RESULTSThe 3-factor was chosen because of the highest

value obtained in the total variance accounted

for by this solution. An initial principalcomponents analysis with varimax rotation wasperformed on the entire sample of the 151respondents but only 140 records were

considered valid. They were included tomaximize the possible range of item responsesthat would affect the inter-correlations between

items entering factor analysis. The followingfactors extracted in the varimax rotation weregiven these labels in describing the process andoutcome of case documentation .


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Factor 1: Record Content. (n = 14). All solely

load on just one factor 0.432 to 0.783. how the

client experiences the world in terms of

orientation to time and place, attitude toward

counseling and what significant others tell about

the client. Facts or quantifiable observations in

terms of the client's general appearance, a

summary of the counselors clinical analysis,prognosis and interventions are portions of these

notes. no. 9: I document what I personally

observed and witnessed (ex. nature of ourrelationship). no. 15: I document action plans

including interventions, treatment, progress and

direction of counseling".


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Factor 2: Brevity of Notes. The second factor extracted in

the varimax rotation consisted of the smallest cluster of six

(6) items with loadings ranging from 0.423 to 0.821. Five

(83%) of these items solely loaded on just one factor. Thisfactor describes the shortness of case notes indicating only

general words and minimum quotes, which are documented

in precise and descriptive ways. The rules are to be observed

in terms of what should be included and how these notes are

written.

Sample items include no. 2:" I document only key words or a

very brief phrase when using quotations." and no. 16: "Mycase notes are brief and concise".


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Factor 3: Writing Mechanics. 10 items, eight

(80%) of them solely loaded on one. This factor

describes how case notes are written and

presented following the rules, format and

standards prescribed by the POMR - SOAP

Model discussed earlier. Likewise, this factor

identifies a number of standards or rules that

should be followed or avoided in writing casenotes. Sample items include no. 24: My case

notes are documented using proper spelling,

grammar and punctuation marks." and no. 30:My case notes are not squeezed with additional

commentary between lines and margins."


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Results identified three factors and

determined the reliability coefficient of

the Case Notes Assessment Scale basedon the 31 items. The Cronbachs

Coefficient Alpha was computed for the

total scale yielding a coefficient of 0.921,indicating a very high level of internal

consistency. Thus, the finding lends

support to the first and second hypothesesof this study:


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In scoring the CNAS subscales and overall, simply add theratings for each item per cluster: For Factor 1, items

include nos. 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 19 and

20; Factor 2, items include nos. 1, 2, 6, 16, 17 and 18;

Factor 3, items consist of nos. 21, 22, 23, 24, 25, 26, 27,

28, 29 and 30. In interpreting the raw scores per subscale

and overall, the following arbitrary scaling was

computed:4.500 and above Strongly Agree (Outstanding)

3.500 - 4.499 Agree (Very Satisfactory)

2.500 - 3.499 Neutral (Satisfactory)

1.500 - 2.499 Disagree (NI)

1.499 and below Strongly Disagree (Poor)


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DISCUSSION

Case Notes Assessment Scale (CNAS) is a

valid and reliable instrument with derived

factors are Record Content, Brevity of

Notes and Writing Mechanics. Findings

suggest that counseling professionals haveto consider these three components in

assessing their case notes to ensure the

appropriate process and outcome of writtenproceedings of the counseling session.


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Findings provided valuable information in mapping

out gaps and limitations in the existing case records

and practices of professionals given the

recommended standards. Validated case note

writing standards serve as guidelines in the conduct

of the profession and in the delivery of better client

care services. This initially developed tool can beused by school counselors, educators, supervisors

and other mental health professionals in evaluating

their case documentation in terms of content,brevity and mechanics of writing notes.


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Results validated the applicability of Cameron andTurtle-Song's (2002) note format standards in

the Philippine milieu. Moreover, in terms of the

number of items left after the factor analysis

procedures, unequal number were observed for

each factor. Factor 1 has 14 items, Factor 2 has

six (6) and Factor 3 has 10 items.

Lends support to a study of Hansen (retrieved

March 23, 2012 from http://www.school-

counseling-zone.com/documentation.html)

suggesting a simple one-page anecdotal notes orsummary of the time spent to a particular student

for referral and/or reporting purposes.


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RECOMMENDATIONS

1. Conduct cross-validity study to give more

detailed properties of the test.

2. Add test items in item bank and larger samplesize for its norming and interpretation of test

scores.

3. Review of individual item or do item analysis.4. Establish norms using other helping professional

populations in the different settings aside from

schools (e.g., community, industrial and clinicalsites).


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REFERENCES

Cameron, S. and Turtle-Song, I. (Summer 2002). Learning

to write case notes using the SOAP format. Journal of

Counseling & Development, 80, 286 292.Estanislao, S. A. (2010). Documenting what has transpired

during the therapeutic hour: An exploratory study. The

Guidance Journal. ISSN: 2094-0599, 38 1, 22-37.

Gable, R. K (1986). Instrument development in the affective

domain. Boston: Klumer Academic Publisher.

Hansen, S. (2009). Documentation Tips and Guidelines.

School-Counseling-Zone.com. Retrieved on March 23,2012 from http://www.school-counseling-

one.com/documentation.html.


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Kiracofe, N. M, Donn, P. A., Grant., C. O., Podolnick, E. E.Bingham, R. P., et. al., (1994). Accreditation Standards

for University and College Counseling Centers. Journal

of Counseling & Development, 72, 38 43.

Prieto, L.R. and Scheel, K. R. (Winter 2002). Using case

documentation to strengthen counselor trainees case

conceptualization skills. Journal of Counseling &

Development, 80, 1121.Sevilla, C. G., Ochave, J. A., Punzalan, T. G., Regala., B. P.

& Uriate, G. G. (1992). Research Methods (Revised

Edition). Quezon City: Rex Printing Company, Inc.

Travers, P. (2002). The Counselors Helpdesk. FamilyViolence Preventions Services, Inc. Books/Cole Thomson

Learning; California.


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Appendix A

Case Notes Assessment ScaleGender______ Age ______ Status __________ Educational Attainment ______________

Years of Counseling Service________ School / College / Univ. _____________________

City / Provincial Address: _______________ Region _______ Email Address: _________

The Counselors case notes are part of the student records,

which are kept in the Counseling Office to ensure the

documentation of annotations, anecdotes, test results,

interventions and proceedings that transpired during thecounseling session or therapeutic hour.

Please indicate your degree of agreement or disagree for

each statement by encircling the number closest to your

response using the following scale:

5 = Strongly Agree 4 = Agree 3 = Neutral 2 =

Disagree 1 = Strongly Disagree


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I document ...

1. what my client tells me in counseling (ex. feelings, plans, goals).

2. only key words or a very brief phrase when using quotations.

3. how my client experiences the world (ex. orientation to time and place).

4. what pertinent (significant) others tell me about my client.

5. my clients (+ or -) change in attitude toward counseling.

6. general words (ex. classmates) rather than names specific to people.

7. facts (ex. clients general appearance, affect and behaviors).

8. quantifiable observations (ex. what is seen, heard or smelled).

9. what I personally observed and witnessed (ex. nature of our relationship).

10. outside written materials received (ex. test results, letters, reports).

11. my summarized clinical impressions, diagnosis or assessment.

12. my analysis of the information and observations (statements 1-10).

13. personal or shadow notes separately kept from student records. 14. prognosis or anticipated gains from counseling (ex. good, fair, poor).

15. action plans including interventions, treatment, progress, direction of

counseling.


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My case notes are

16. brief and concise.

17. written with minimum quotations.

18. documented in precise and descriptive terms.

19. recorded using an active voice (noun-predicate sentence structure).

20. written immediately after each counseling session.

21. separated by date, time and the number of the counseling session.

22. written legibly and neatly.

23. documented using proper spelling, grammar and punctuation marks.24. complete with contracts or attempted contracts (if needed).

25. handwritten using only black ink (if not encoded).

26. signed-off using my signature and title or position.

27. not with value-laden language, common labels and opinionated items.

28. prepared with no blank spaces in-between entries.

29. not squeezed with additional commentary between lines and margins.

30. Overall, I assess my case notes as well-documented.


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Authors NotesEmail Address: [email protected]

Office telephone no. (02) 536-0226

Suicide Potential Inventory for Filipinos

BDI tel. nos. (02) 4187025 to 26

Thank you. God bless!

e1 estanislao towards the development case notes

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