DRS Rehabilitation Policy Manual Chapter 1: Foundations, Roles, and Responsibilities

Revised December 2015

1.2.8 Reflecting Quality Program Management in Documentation

(Revised 09/09, 03/10, 11/10, 05/11)

The management of the Texas VR program is largely reflected in the case file documentation of each consumer. A key to the program success is your ability to demonstrate accurate and timely decisions that

  • comply with the law;
  • are made in partnership with the consumer; and
  • lead to the delivery of substantial services for the eligible consumer, ultimately resulting in suitable employment.

Case file documentation includes:

  • information contained in the electronic case managementReHabWorks (RHW); system,
  • information contained in the paper case file;, and
  • case notes.

Use case notes to compile information gleaned from the other two sources, and from your interactions with the consumer, the consumer's family or representative, referral sources, service providers, and others, in order to:

  • convey compliance with federal and state laws regarding:
  • use of funds;, and
  • decisions in service delivery;
  • document your decision making and application of the VR process;
  • provide a clear and concise explanation of the consumer's progression through the rehabilitation process;
  • make clear the outcomes of planned interventions;
  • ensure the ability to seamlessly provide services to the consumer in the absence of the counselor of record; and
  • establish a sound record of program effectiveness and efficiency.

Clear written communication is required to achieve these expectations. Policy often refers to the need for incidental case notes to explain or justify a course of action. You should write these case notes objectively, clearly, and concisely for the reasonable reader to understand. Documentation must add value in the public VR program by revealing relevant information about

  • the consumer's participation in and progress through the VR process,
  • the staff's considered decisions, and
  • the outcomes of planned interventions.

In addition to prescribed incidental case notes, at a minimum, every electronic RHW case file must document the activity that was performed for or with the consumer, as described in the following table.

Activity / Documentation
Application and diagnostic interview / A case note or series of case notes that describes pertinent information garnered from the consumer, the consumer's family or representative, and any available records. to include
The case note must include:
  • a thorough examination of the consumer's work history;,
  • enough information or identified gaps in information needed to determine the consumer’s eligibility for services (or to identify the information that still needed for determining eligibility), ; and
  • the information that will be needed may be used later during assessment to develop an Individualized Plan for Employment the (IPE) for the eligible consumer;
  • the consumer’s perspective on his or her disability and how it affects the consumer’s ability to prepare for, obtain, maintain, keep, and advance in competitive integrated employment;
  • information about the discussions with the consumer related to informed choice, such as the consumer’s initial goals and expectations for VR services; and
  • detailed plans for obtaining records or scheduling necessary assessments to determine the consumer’s eligibility.
Example of a case note for an application and diagnostic interview case note
Opening or reopening a previously closed case / A case note or series of case notes that describes:
  • the circumstances surrounding of previous closures and the need for opening a case;
  • the changes that will lead to a successful case outcome; and
  • consultations with the area manager, if applicable.
See Chapter 2: Initial Contact and Application, 2.7 Opening a New Case Reopening or Adjusting the Phase of a Previously Closed Case, for more information.
Determination of eligibility / A case note or series of case notes that describes:
  • the information that supports how the criteria for eligibility are meteach eligibility criterion is met;, or
justification for using pre-eligibility trial work, and
the circumstances leading to a determination of ineligibility;, or
  • the process of an extended evaluation andincluding the clear and convincing evidence for that determination, led to the eligibility or ineligibility decision.if the ineligibility decision was due to the severity of the consumer’s disability.
For Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) cases that are presumed eligible, document the presumption of eligibility and the reported disability.
For cases involving SSI or SSDI and SSI-D or SSDI cases that are not immediately presumed eligible for DRS services immediately, document in a case note what precluded immediate presumption of eligibility in a case note.
Examples of case notes for eligibility determination case note
Level of Significance / A case note that describes how the consumer’s disability affects his or her functional capacities and meets the other criteria for establishing the disability’s level of significance (see Chapter 19.2.7 Designating the Level of Significance for more information)
or
A completed DARS1390, Checklist for Determining Significance of Disability. If the DARS1390 is used, meet the documentation requirement by also completing a case note in RHW that the form was completed.
Document the disability’s level of significance as a stand-alone case note or as part of a case note for eligibility or assessing and planning.
Assessing and planning / A case note or series of case notes that shows how the assessment: resulted in
  • provided information on the consumer’s disability (including a review of existing records, when available, and a review of new assessments, when necessary);
  • resulted in the identification of the consumer’s strengths, resources, priorities, concerns, abilities, capabilities, and interests;
  • resulted in the identification of the consumer’s potential employment goals;
  • led to the making of decisions that support the goals, objectives, and services identified in the consumer’s of the IPE;
  • led to the consumer's participation in informed choice; and
  • led to development of the plan for making contact with the consumer.
For consumers who are high school students, the case file must demonstrate coordination of the IPE with the goals, objectives, and services identified in the consumer’s individualized education plan (IEP) or the consumer’s 504 plan.
Examples of case notes for assessing and planning case notes
Changes to the original IPE that result from:
  • a joint annual review;,
  • other amendments;, or
  • post-employment services.
/ A case note or series of case notes that describes: the
  • the results of the plan review;
  • the reasons for any changes that do not require an amendment; or
  • the reason for an amendment and the nature and scope of the changes, including how objectives, services, and a plan for communication with the consumer were developed, when applicable.
Examples of case notes for IPE changes case note
Service delivery notes / A case note or series of case notes that describes:
  • the decisions that support the necessary provision, extension, or addition of a VR service; or
  • the consumer’s role in the decision making process;
  • the actions taken to provide the service, such as:
  • considering best-value information;,
  • taking purchasing or technical actions;,
  • making or receiving service delivery contacts;, or
  • conducting follow-up service delivery activities.
Examples of case notes for service delivery notes case note
General contact notes / A case note or series of case notes that describes the consumer's rehabilitation story that includes relevant by reflecting conversations, observations, decisions, and actions that support the consumer's progress, and informed choices.
Examples of case notes for general contact case note
Counseling and guidance / A case note or series of case notes that reflects the skillful application of counseling strategies and interventions, such as to on topics such as:
  • remove removal barriers;,
  • help solve problemsproblem solving;,
  • provide information and support to help the consumer make an informed choices;, and
enhance the consumer’s an adjustment to a their disability;, and
  • educate.
Whenever possible, use the case note title “counseling and guidance” in ReHabWorks to clearly demonstrate that counseling and guidance was provided.
Example of case notes for counseling and guidance case note
Joint annual review (JAR) / A case note or series of case notes that describes JAR activities related to a joint annual review (JAR), such as review and discussion of the consumer’s:
  • personal information;,
  • progress in achieving the employment goal;,
  • intermediate goals;, and
  • responsibilities.
Example of a case note for a joint annual review (JAR) case note without an IPE amendment.
If an amendment to the IPE is required, see the table row (above) on section “Changes to the original IPE that result from:
  • a joint annual review;,
  • other amendments;, or
  • post-employment services.”

All closures / A case note or series of case notes that describes:
  • the reason the case was closed;,
  • the circumstances that led to the closure decision to close the case;, and
  • how the case meets the any associated criteria required for closure.
See Also see Chapter 16: Closure, 16.2.9 Closing Successful Cases or Chapter 9: Employment Services, 9.13.10 9.6.10 Closing a Case as Rehabilitated for self-employed consumers.
Examples of case notes for case closure case note

Certain Some special circumstances in policy require specific documentation to implement a service or take some other action. The following table describes the minimum documentation required for these circumstances.

Action / Documentation
Services to family members / A case note or series of case notes that describes:
  • why services are needed;,
  • which family member or members need the services (names and Social Security numbers);,
  • what services are needed;, and
  • how the services are expected to contribute to the consumer's employment.
Example of a case note for family member services case note
Homemaker closure / A case note or series of case notes that describe
how the employment goal of homemaker was determined to be the most suitable; and
how substantial service delivery has significantly helped the consumer perform homemaking activities to the extent that either
othe consumer no longer requires the services of a paid or volunteer housekeeper, or
oa family member has been freed to seek or continue employment.
Example of homemaker closure case note
Identification and/or use of comparable benefits / A case note or series of case notes that describes the progress made in accessing and applying for identified comparable services and benefits, including applying for and obtaining or being denied application for and use or denial of a Pell grant, when applicable.
Data integrity / A case note or series of case notes that describe changes in system data for correction.
Adding "Consumer requires special attention" / A specific and factual report including
  • the date,
  • the location,
  • the names and addresses of witnesses and people involved,
  • what was said or done, and
  • the names of those willing to testify.
If it is later determined that the consumer no longer poses a threat, enter a new case note that describes the change in circumstances.
Removing "Consumer requires special attention" / A case note or series of case notes that describe why the consumer no longer poses a threat.
Management resets PIN / A case note or series of case notes entered by management that describes:
  • an action taken;, and
  • the reason that the consumer’s PIN was reset.

Action requiring management approval / A case note or series of case notes entered by the approving source, that describes:
  • the decision requiring for approval;,
  • the parameters of approval;, and/or
  • the extent to which a relevant policy is being waived.

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