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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
!
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: susana.estanislao@dlsu.edu.ph
Office telephone no. (02) 536-0226
Suicide Potential Inventory for Filipinos
BDI tel. nos. (02) 4187025 to 26
Thank you. God bless!
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