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 NotesCollateral contacts are basically all non-face to face contacts involving the client. This can included but not limited to the following:
