Notes and Narratives 535-05-65

(Revised 4/1/12 ML #3326)

View Archives

Include all information relevant to the client obtained during the assessment process that was not entered in a comment or note field for ADLs or IADLs. A signed and dated hard copy of the assessment including the narrative must be kept in the client file.

All contacts relating to a client must be noted in the narrative section of the comprehensive assessment. Notes maintained in any other format are not considered valid. When applicable, notes/narrative should include the following:

• Date
• Reason for contact (i.e. initial, annual, six month, collateral, returned call, received call)
• Location of visit (i.e. home visit, care conference, hospital visit, office visit, telephone contact, letter sent)
• A description of the exchange between the case manager and the client or the collateral contact
• A listing of identified needs
• Service delivery options
• Summary of care plan
• Client satisfaction and follow-up plan
• Initial’s of Case Manager completing the note or narrative

HCBS Case Managers Record Management System

• The HCBS Comprehensive Assessment is a web-based product of Synergy Technologies. The HCBS Comprehensive Assessment enables the HCBS case manager to record the applicant's/client's functional impairment level and correlate that to the need for in-home and community-based services.

DD Case Managers Record Management System

• The DD Case Managers comprehensive assessment consists of three components;

1. Case Plan in THERAP that identifies the desires outcomes and all services the individual is receiving.
2. Progress Assessment Review (PAR) in THERAP that includes information regarding diagnoses, medications, behavioral issues, psychiatric, legal and support needs. The PAR and Case Action Form also serve as the ICF/MR level of care screening.
3. Personal Care Eligibility and Needs Assessment for DD that determines whether the specific eligibility for Personal Care Services are met.