Legal

TCM Tip: Addressing Names Within the Case Note

By March 14, 2023May 3rd, 2023No Comments

When completing case notes, include the first and last name, agency, and title of the person you reference in the note (provider, supervisor, mother, friend, etc.).

EXAMPLES OF GOOD CASE NOTE CONTENT

  • Called Jane Doe, ABC Home, about issues with Sam missing work. Left a voicemail with Sam to call me about her absences at work in order to see if there are any issues.
  • Met at Tina’s home and completed a quarterly review of Tina’s service plan. I introduced to Cindy Smith, Tina’s new SSA. See the service plan for more details.

EXAMPLES OF BAD CASE NOTE CONTENT

  • Received a call from Jan about Mike and was told services were good.
  • Printed, copied, and mailed out the service plant to Mary, John, and Lucy.