Michelle March, PhD Wednesday 9:00 P. M.

Documentation and Recording Case Manager’s Responsibility to keep a record of all contacts relevant to each case. Legal purposes Administrative purposes

Contact Notes Should always include the following: 1. The focus of the interview 2. Your assessment based on a concise summary of behavior, appearance, affect 3. Any resolution that takes place 4. The reason fore the next contact or follow-up that will occur

Labeling the Contact Always date the contact Provide one of the following types of contact: Collateral Office Visit Phone Site Visit Group Home Visit

Documenting Service Monitoring Documentation: The Finishing Touches Present notes as Professional Avoid Hostility Document your interaction with the client Document significant aspects of the contact Be clear and precise Use quotations Avoid contradictions Use language clients can understand Accurately describe disabilities

Government Requirements Must follow state and federal government requirements in order for documentation to be reimbursed. General requirements include: Use black ink Never use pencil or correction fluid Write eligibly Identify your clients by name on each page of the documentation. Do not use nicknames or initials. Record actual date Correct mistakes following procedure Draw a line through any black lines left on the document and diagonal lines through black spaces

Do Not be Judgmental Use appropriate wording to avoid sounding judgmental Refer to Figure 24.3 on page 372 of the text

Distinguish Between Facts and Impressions Give a balanced picture of your client Provide evidence of agreement Making changes to the plan If there is a lack of progress toward the original goals Note the lack of progress in the notes Note the recommend changes to the treatment plan in the notes Revise the treatment plan See the Appendix for samples of contact notes.