We all know documentation is a key component in the human services field. Progress notes along with other reports serve as confirmation that services were provided as indicated on the client’s treatment plan. Depending on the agency or specific program, progress notes can be completed on a daily, weekly or monthly basis. Case management programs typically complete daily progress notes while residential and day support programs might complete a note after each shift or write a weekly summary note.
Progress notes are important because they provide a report of the client’s previous and current services while in the program. These notes should read like a story of the client’s success (or lack thereof) from intake to the present. A new case manager or clinician should be able to pick up a chart and understand the client’s current status and needs based on reading the progress notes. In addition, progress notes as well as other documentation could be subject to subpoena and FOIA (Freedom of Information Act) requests in some situations. This is why it’s important to have accurate, detailed progress notes.
The obvious and most important reason for progress notes are that they are directly tied to reimbursement for services. The progress notes serve as proof that the services were rendered. Insurance companies periodically review these notes during the auditing process to ensure that they are paying for services that are provided in compliance with state, local, and agency regulations.
Case management progress notes tend to be more detailed due to the long-term nature of the services. Intellectual disability case management progress in particular are more detailed since these services will likely be in place for the lifetime of the client. In this post I discuss the two primary notes that case managers perform on a daily basis. These notes are collateral contact notes and face to face progress notes.
Collateral Contact Notes
Collateral contacts are basically all non-face to face contacts involving the client. This can included but not limited to the following:
*Phone contact with the client, family, or service providers
*Reviewing provider progress notes and quarterly reports
*Referrals for services
Collateral contact notes can vary in formats depending on the agency. In general, the collateral contact note addresses some form of case management activities, client observation, and follow up regardless of the format.
Case Management Activities – It seems simplistic but just explain exactly what you provided for the client. Important key words such as linked, monitored, coordinated, and referred are suggested in this area to show that the case manager is providing the services according to Medicaid requirements.
Client Observations – This area should discuss how the case manager’s actions will impact the client. This is also where the current status and progress are documented. This section is also where the discussion of progress or lack of progress on specific goals (or desired outcomes) will take place. You would document any problems or concerns expressed by the client or the family as well as any significant events. You also want to mention satisfaction and/or dissatisfaction with services.
Follow Up Needed- This section discusses any unmet needs or additional planning for the next visit or contact.
Face To Face Notes
Face to face notes include all the components of the of the collateral contact note. However, the face to face note is expected to be a little more detailed due to the ability to make direct client observations and speak directly with the client and support staff. In addition, case managers can also review behavior logs, progress notes or any other documentation.
Location- It’s important to document where the face to face contact took place. Some states may require that a specific number of visits occur in the home.
Who was Present- As with collateral contact notes, it’s important to document who you talked with and who was present at the face to face meeting. It’s a good idea to include the name and title when possible (ex. Case manager spoke to “John Smith” (Program Director). In many cases talking to direct care staff can provide a better picture of the client’s progress. In other settings such as group homes, it might be better to speak with a house manager or supervisor during the visit. This is largely due to shift changes and staff turnover.
Client Observations – The face to face note should provide more details of the client’s physical and emotional state. Direct conversations and observations provide a better opportunity to gage progress. It’s important to note any changes in physical appearance as well as observation of mood and
emotional well-being. This is also an opportunity for the client to tell you directly if they are satisfied or dissatisfied with services and discuss solutions to any concerns.