Developmental Services - Case Management Manual

Action Notes/Contacts

Case Managers are expected to maintain regular consumer contacts, and to maintain regular action notes. Both contacts and action notes should be at least monthly, unless otherwise specified (see below). All consumer billings must be supported by an appropriate action note, which is documented by the Case Manager using the standards outlined below.

All action/contact notes are to be done on the EIS system .

Contacts should occur often enough to assure that the Case Manager remains apprised of the consumer's status and well being, as well as maintaining familiarity with any providers who are serving the consumer. Whenever applicable, the Case Manager should arrange his contacts so that he visits the consumer in the full range of settings in which the consumer lives, works, and socializes.

Face-to-face contacts are preferred, but a phone contact may be substituted if scheduling conflicts prevent a direct visit, or if the consumer does not wish to have direct contact with the Case Manager. In either of these cases, the Case Manager's action note should reflect this fact. Email contact can occur but should not be a routine means of contact with the consumer. Email contact with family, guardian, providers etc can be an effective means of communication. Portions of this communication can be pasted into a contact note in order to provide direct and pertinent information. The entire email should not be pasted and an introduction and final statement should be included in the contact note by the case manager.

Action Note Requirements (2003 Action Note Training)

Web Based Training- http://www.ipsitech.org/doc/

Minimum:

  1. Sign (full name-classification “CM,”)
  2. Date (full date-month, day, and year)
  3. Link to plan when relevant

Action Notes:

  1. Place of contact
    1. Residence, vocational, etc.
  2. Type of contact (and who was present)
    1. Face-to face, telephone, collateral, etc.
  3. Observation
    1. Issue(s) events surrounding quality of life areas, changes in medical and dental condition, etc.
  4. Action
    1. Action(s) that have taken place or take place in the contact
  5. Follow-Up
    1. Action(s) that need to take place

Action notes should be done at least monthly, and in conjunction with the date of the contact.

Notes should include:

  • PCP or other significant meetings and follow up documentation related to theses meetings.
  • A summary of the contact and the overall status of the consumer as observed and/or described.
  • Ongoing notations on any problematic or unresolved issues. Longstanding patterns with frequent recurrences (e.g.), rep payee disagreements, arrests, substance abuse episodes may be noted with a brief notation, so long as there is a longer, characterizing summary included in the notes at least biannually.
  • Any major or life-altering events, both positive and negative.
  • Any changes in family or marital status
  • Significant actions undertaken by the Case Manager or other members of the team, relative to the consumer's services.

Action notes should be prepared as soon as possible after the contact in any case, within 10 workdays.