Do your notes reflect the Reason, the Action, and the Progress or outcome of the contact? (remember R.A.P.)
- Do your notes address the plan/needs during the contact?
- Do your notes state the location where services were provided?
- Do your notes provide a clear summary so someone else reading the notes can understand what has occurred?
- Do your notes show continuity of care?
- If one note states an ISP revision is needed, is there another note showing the revision was completed?
TCM Case notes should reflect significant contacts related to an individual regarding the provision of services and include coordination of services and supports and continuous review process activities.
