Developmental Services - Case Management Manual

Consumer Files/Record Keeping

Keeping an accurate and current account of significant events in our consumer's lives, services provided, and evaluations performed are extremely important. Good record keeping can greatly enhance the continuity of case management services by accurately reflecting that the wishes of our consumers are the focal point of all services requested and provided.

The case record should include, but is not limited to, the following;

  1. Relevant demographic information is maintained in E.I.S..
  2. If the consumer is deaf, non verbal and signs or is familiar with another spoken language the name and contact information regarding a qualified interpreter or individual who is familiar with the consumer's communication style.
  3. Copies of the most recent and pertinent evaluations (i.e.; psychological, psychiatric, O.T., P.T., Speech, etc.).
  4. Medical and dental information. Indicate where primary medical information is (i.e.: residential file at supporting agency).
  5. Copies of the individual's annual plan/behavior protocols, if used.
  6. Action notes are maintained in the E.I.S.
  7. Guardianship information
  8. Evidence of any legal/judicial involvement
  9. Correspondence
  10. Copy of mortuary trust/funeral arrangements, if any
  11. Certification materials for the waiver program, if applicable/other housing information
  12. Financial information/SS/SSI/VA/RR etc.
  13. Quality assurance/consumer satisfaction information
  14. Information on best method for communication, preferred interpreter, or where to locate a "dictionary of communicative intent" for individuals with unique communications styles.