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SECTION 320: CASE RECORDS AND CASE RECORDING

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REVISED: 04/01/06

I. CASE RECORDS

Federal Regulations require that the North Carolina Division of Services for the Blind maintain a record for each consumer. The record will contain pertinent information about the consumer and the services he/she receives. All information as to personal facts given or made available to the agency in the course of administration of the Independent Living Services Program will be held confidential. Refer to Manual Section 300, VII B.2.b. p.20 for additional information on confidentiality policies.

If the SWB needs to obtain an eye report or other health information, it is necessary for the DHHS-1000 Authorization to Disclose Health Information to be completed and signed by the consumer. A copy of this form must remain in the case record. See Section 500 for a copy of the form and the instructions for it’s use.

The case record provides the only source of sequential information regarding the consumer's situation. All workers will maintain individual case records on each consumer for whom they have service delivery responsibility. Each record will contain a paper copy of all work done even when the SWB has done forms, narratives, etc. electronically. Social Workers for the Blind will also maintain central or composite files of all applicants found ineligible for independent living services. Also, Resource Specialists will maintain central or composite files for all referrals they reject for specialized services.

A. Contents of Case Records

B. Retention of Case Records

II. CASE RECORDING

Social Workers for the Blind, Independent Living Rehabilitation Counselors and Orientation and Mobility Specialists are responsible for maintaining case recording for all consumers in the Independent Living Services Program for whom they have case management and/or service delivery responsibility.

Case recording entries must be made by all workers at least quarterly. A summary of several contacts made during the report quarter may be recorded in one quarterly entry, if desired. All case recording is maintained in the consumer's case record.


A. Purposes of Case Recording

B. Guidelines for Case Recording

2. Case activity

C. Closing and Transferring Cases Moving Out of County

Service cases in which the consumer is actively receiving services at the time he/she moves to a second county in North Carolina must be closed or transferred immediately after the date the consumer moves from the first county. A closing summary, such as illustrated on the following page, must be prepared.

EXAMPLE of Case Recording and Closing Summary

When consumer was referred to this agency, she had lost the ability to function independently due to her poor vision and depression. Counseling services enabled consumer to cope with the depression and anxiety which were a result of to her vision loss. This counseling helped the consumer's understanding and enabled her to develop a positive attitude about herself and to function independently in her home and community.

Independent Living skills training and adaptive equipment enabled consumer to better compensate for her visual loss. The consumer can now prepare meals, use her stove safely, clean and organize her house, thread a needle, dial the phone and identify money. Orientation and mobility training has enabled consumer to travel up and down stairs, cross streets safely and travel independently around her community.

If the consumer indicates he/she wishes to continue receiving services from the agency in the county to which he/she is moving, the Social Worker for the Blind will transfer the case record with a closing summary. One copy of the closing summary is to remain in the first county. The original is to be sent to the second county with a copy of the current eye report.

D. Service Responsibility to Out-of-County Residents

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