Include Names and Titles in Case Notes—Except When Referring to Other Individuals Served
When documenting case notes, always include the full name and title of any persons involved in the conversation or activity—such as family members, providers or team members.
Example of appropriate documentation when referencing others:
“Spoke with James (brother) about the new work schedule the individual received.”
Exception: Do not include the names of other individuals served in case notes.
Example of appropriate documentation when referencing another individual served:
“Spoke with the individual about the incident between her and her friend (another individual served).”
If you have questions about anything TCM-related, please contact us at TCMTeam@medicaidbillingsolutions.com.
