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First Steps: Service Coordinator
Unit V Lesson 3: Case notes
The following notes are good "rules of thumb" to use when deciding what to include in case notes. Also included are items that are good to chart.
Characteristics of Good Case Notes
Child’s name/ID is on every page
Entry is legible
Black ink is used
Each entry is dated (month/day/year)
Each entry indicates start and end time of each activity
Each entry is signed
No lines are left blank between entries
No white- or black-out of words
Errors are noted with a single line through and an initial
Late entries are identified with “late entry”
Use of abbreviations is limited to standard symbols only
People discussed are identified (such as Jane-mom, Sue-speech therapist)
What to Chart
Telephone messages received and messages left
Discussions and interactions relevant to IFSP with: family members, providers, and community agencies/ resources
Instructions to the family
Discussions about procedural safeguards presented to family
Summary of visits/contacts with: family, providers, and other community agencies/resources
Key Points in Writing Case Notes
1. Use only adjectives that are defined, necessary, and clinically appropriate; when possible, replace an adjective with a verb that describes behavior
2. Avoid clichés like the plague
3. Leave out subjective comments about the family
4. Leave out incomplete information (example: Incorrect: “Child referred to Jim”; Correct: “Jonathon was referred to James Thomas, M.D.”)
5. Leave out non-pertinent information
6. Leave out untrue information (fraud can be grounds for disenrollment from the First Steps CFO)
Missouri Documentation Requirements
Submit progress notes to the SPOE quarterly
Monthly progress notes from the providers (see Service Provider Progress Notes’ daily and monthly forms at end of this resource)
Distribution of Copies
Originals go to the official early intervention record at the SPOE
Copies to family, providers, and service coordinator
Case Notes
Characteristics of Good Case Notes
No white- or black-out of words
Errors are noted with a single line through and an initial
Child’s name/ID is on every page
Entry is legible
Black ink is used
Each entry is dated (month/ day/year)
Each entry indicates start and end time of each activity
Each entry is signed
No lines are left blank between entries
Late entries are identified with “late entry”
Use of abbreviations is limited to standard symbols only
People discussed are identified (such as Jane
mom, Sue-speech therapist)
What to Chart
Telephone messages received
Instructions to the family
Discussions about procedural safeguards presented to family
Summary of visits/contacts with family
Summary of visits/contacts with providers
Summary of visits/contacts with other community agencies/resources
Telephone messages left
Discussions and interactions with family members relevant to IFSP
Discussions and interactions with providers relevant to child and IFSP
Discussions and interactions relevant with community resources relevant to child and IFSP