I had an interesting experience during a training session on Good Clinical Documentation at Milwaukee County On our handout were examples of notes that might have been written regarding case managers encountering mental health consumers. The notes included plenty of low hanging fruit with egregious examples of opinions stated as if they were facts. The case manager was supposed to be doing a lot of med monitoring in these examples. But of course the consumer was an alcoholic. The case manager’s dislike for this woman, Mary, showed through from the very beginning and grew worse.
Aside from checking on her medication, the case manager, Jane, was supposed to be helping her to find housing. Here, Jane proved to be the case manager from hell. There was one message about housing applications without any hint of follow through. As if Jane could not be bothered. The worst note from Jane was when she wrote that Mary had shown up to meet with her in a restaurant without her pill-box so she could check it. As soon as I read that, I spoke up, declaring that such a move would have violated Jane’s right to privacy. People who receive case management services do not deserve stigma. I would no more dream of checking anyone’s medication in public than I would go to the bar for a few drinks with a consumer.
People who taking psychotropic drugs need their privacy and deserve to be assisted in the least restrictive environments possible. In the final note regarding Mary, it was discovered that Jane died in her apartment and had not been observed by Mary for weeks. She did not do a wellness check and she did nothing to help her. Obviously, no case manager worth her paycheck would treat anyone like that, would they?