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.
