Case Noting

Case Note Components

  • Date of contact.
  • Length of contact (to nearest quarter hour.)
  • Type of contact (phone call, face to face visit, team meeting, annual plan, doctor visit, etc.)
  • Summary of contact (such as: names of people present at meeting, short summary of contact.)

Frequency of Contact Requirements (Minimum)

  • Mandatory face to face contact within the first 30 days of services
  • Direct of collateral contact occurs every month. This may include face-to-face; telephone; e-mail; voice mail; fax; or written exchanges with the individual, their medical or service providers, family or other with knowledge of their long-term care needs.
  • Contacts billed to Home and Community Based Waiver reflect a two way transmittal of information directly related to an individual’s medical, physical, or emotional status.
  • Face-to-face contact with each participant every three months. Annually, one visit must occur in the individual’s home.
  • Review of the individual service plan during a face-to-face meeting with the participant every six months.

Case Note Protocol When Interviewing Prospective Consumers/Guardians

  • Support Brokers should only count interview time on their agency 610 if they get hired by the prospective consumer/guardian.
  • Support Brokers should not log the time that it took to set up the interview (e-mails, phone calls, reciprocal communication, etc.)

Why are case notes important?

  • You can use this information when compiling and writing an annual plan or CIP update.
  • You can refer back to this information for court reports or other documents that you may have to write.
  • You develop a written history of a person’s life. For example, you can answer the question, “What year did we stop that medication?” or “When did Billy move to the duplex?”
  • Medicaid waiver (CIP) requires case notes.
  • Every year the state completes a random audit of Case Management and Broker records. This might mean you!