© 2015 National Skill Set For Effective Case Management in AUS & NZ: Skills Workbook

The CM cannot provide documentation to show that they have made/discussed referrals to appropriate services to facilitate independence [S2B] CM does not maintain accurate records [S2D] Goals are not adequately constructed. Goals are absent/not recorded [S2E] There is no documentary evidence by CM to show that the Client has been given a copy of agreed goals/care plan [S2E] CM documentation does not identify/support Client consultation [S2F] Contact with the Client is not adequately documented [S3A] Documentation does not demonstrate the timely advisement of changes affecting Clients [S3A] No documentation by CM. Conflict identified but no action taken to rectify [S3B] CM documentation does not demonstrate allocation of roles/ responsibilities between multiple stakeholders [S3B] CM is unable to demonstrate engagement with key stakeholders (both formal and informal) where these are deemed essential in the Client achieving their agreed goals [S3C] CM is unable to demonstrate the review and modification of care plan in response to changes to the Client’s needs and interests [S3C] CM is unable to demonstrate that actions/interventions have been implemented in accordance with the Client goals within care plan [S3C] CM is unable to demonstrate communication with Client regarding limitations and/or variations to resources, services and support; including disengagement [S3C] CM is unable to provide examples of statutory/ mandatory reporting specific to their area of practice [S3D] CM documentation does not demonstrate evidence of risk stratification undertaken by CM [S3D] The CM cannot demonstrate Client choice or involvement in accessing appropriate services, supports and resources [S3E] CM is unable to demonstrate how they test the Client’s ongoing ability to advocate for themselves [S3E] There is no documentation by CM to show that reviews have been carried out as requested by the Client [S4A] There is no documentation by CM of formal evaluations [S4A] There is no documentary evidence by CM that rights and responsibilities have been reviewed and discussed with the Client [S4A] Documentation by CM does not demonstrate the comparison of actual outcomes against expected outcomes recorded within Client goals [S4A] No documentation by CM to show feedback from key stakeholder has been received and used to evaluate Client progress/experience towards agreed goals [S4A] Client outcomes are not recorded by CM in accordance with agency/ program and/or funding body guidelines and/or policies and procedures [S4A] Documentation by CM demonstrates no amendment to the agreed goals within the care plan arising from Client feedback and evaluation [S4D] CM does not document quality of life factors [S4D] CM documentation does not demonstrate evidence that Client goals have been met [S4E] CM documentation demonstrates no Client and key stakeholder feedback is sought and received by CM [S4E] Standard 1A – 1H, Standard 2A – 2F, Standard 3A – 3E, Standard 4A, Standard 4D – 4E Documentation by the CM demonstrates the CM has obtained the Client’s informed consent at the commencement of the program. The CM facilitates an alternative option for a Client who is unable to sign a consent document [S1A] Documentation by the CM demonstrates the facilitation of Client research, interviews and the acquisition of information (including previous assessments and referral information) to establish the factual basis to proceed with the assessment [S1B] The CM documentation demonstrates the CM has accessed/utilised appropriate information and resources to meet the Client’s individual, diverse and/or special needs [S1D] The CM in partnership with the Client and key stakeholders prioritise risks and possible risk management strategies. These risks and strategies are documented [S1E] Skilled

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National Skill Set for Effective Case Management Workbook

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Chapter One