How well you document each consumer’s case directly affects the quality of the services that you provide the consumer.

A key to the CRS program’s success is your ability to document accurately and in a timely manner the decisions that:

  • comply with the law and with state rules;
  • are made in partnership with the consumer;
  • result in the eligible consumer receiving services; and
  • result, ultimately, in the consumer’s increased independence at home and in the community.

The type of documentation kept in the case file includes:

  • information contained in ReHabWorks (RHW), including case notes; and
  • information contained in the consumer’s paper case file.

Create case notes in RHW to compile information gleaned from other sources, and from your interactions with the consumer, the consumer's family or representative, referral sources, service providers, and others, in order to:

  • convey compliance with state laws regarding the:
    • use of funds; and
    • decisions made about service delivery;
  • document your decision-making and application of the CRS process;
  • provide a clear and concise explanation of the consumer's progress through the rehabilitation process;
  • make clear the outcomes of planned interventions;
  • ensure the ability to seamlessly provide services to the consumer in the absence of the counselor of record; and
  • establish a sound record of the program’s effectiveness and efficiency.

Clearly written information is required to achieve these expectations. This manual often refers to the need for writing incidental case notes to explain or justify a course of action. When writing case notes, be objective, and write clearly and concisely enough for the reasonable reader to understand.

Your documentation must add value to the CRS program by revealing relevant information about:

  • the consumer’s participation in and progress made through the CRS process;
  • the staff member’s considered decisions; and
  • the outcomes of planned interventions.

In addition to prescribed incidental case notes, at a minimum, every RHW case file must document the actions taken on behalf of or with the consumer, as described in the following table.

Activity

Documentation

Completing an application and diagnostic interview

A case note or series of case notes that describes pertinent information obtained from the consumer, or the consumer's family or representative, and any available records, including :

  • information after a thorough examination of the consumer's medical history;
  • information or identified gaps in information needed to determine eligibility; and
  • information that may be used later during assessment to develop the Individualized Written Rehabilitation Plan (IWRP) for the eligible consumer.

Opening or reopening a previously closed case

A case note or series of case notes that describes the:

  • circumstances leading to previous closures and the need for opening a case;
  • changes needed for a successful case outcome; and
  • consultation with the manager, if applicable.

Determining eligibility

A case note or series of case notes that describes:

  • how the criteria for eligibility are met; or
  • the reasons for a consumer’s determination of ineligibility.

Assessing and planning

A case note or series of case notes that show how the assessment resulted in the:

  • identification of potential goals;
  • decisions that support the goals, objectives, and services of the IWRP;
  • consumer's informed choice; and
  • development of the plan for contact with the consumer.

Making changes to the original IWRP that result from:

  • a Joint Annual Review; or
  • other amendments.

A case note or series of case notes that describes the:

  • results of the IWRP review;
  • reasons for any changes that do not require amendment; or
  • reasons for an amendment and the nature and scope of the changes, including how objectives, services, and a plan for communicating with the consumer were developed, when applicable.

Service delivery notes

A case note or series of case notes that describe:

  • the decisions that support the necessary provision, extension, or addition of a service; or
  • actions taken to provide the service, such as:
    • using best-value information;
    • completing technical tasks or purchasing-related tasks;
    • making contacts; or
    • following up.

General contact notes

A case note or series of case notes that describes the consumer's rehabilitation story by reflecting conversations, observations, decisions, actions taken that support the consumer's progress, and the consumer’s opportunities to make informed choices.

Counseling and guidance

A case note or series of case notes that explains how counseling strategies and interventions were skillfully applied to support the consumer; for example, were applied to:

  • remove barriers;
  • help solve problems;
  • provide information and support to help the consumer make an informed choice;
  • help the consumer adjust to a disability; and
  • educate the consumer.

Joint annual review (JAR)

A case note or series of case notes that describe JAR activities, such as reviewing and discussing the consumer's:

  • personal information;
  • progress in achieving independence;
  • intermediate goals; and
  • responsibilities.

Closing a case

A case note or series of case notes that describe:

  • the reason the case was closed;
  • the circumstances that led to the decision to close; and
  • how the case meets the criteria for closing a case.

Specific documentation is needed before certain actions can be taken. The following table describes the minimum documentation required.

Action

Documentation

Services to family members or caretakers

A case note or series of case notes that describe:

  • why the services are needed;
  • which family members or caretakers need the services (include names and, if provided, include Social Security numbers);
  • what services are needed; and
  • how the services are expected to contribute to the consumer's goal of independence.

Identification and/or use of comparable benefits

A case note or series of case notes that explains the progress made toward accessing and applying for identified comparable services and benefits.

Making data corrections (maintaining data integrity)

A case note or series of case notes that describes data corrections in ReHabWorks, including the justification for the corrections and the approval obtained.

Adding "Consumer requires special attention"

A specific and factual report of the event that lead to the determination that the consumer poses a threat, including:

  • the date of the event;
  • the location of the event;
  • the names and addresses of witnesses and people involved;
  • an account of what was said or done; and
  • the names of those willing to testify.

Removing "Consumer requires special attention"

A case note or series of case notes that describes why the consumer no longer poses a threat.

Resetting of a Personal Identification Number (PIN) by a CRS program manager

A case note or series of case notes entered by a manager to:

  • note that the manager reset the PIN; and
  • explain the reason for resetting the PIN.

Obtaining management approval

A case note or series of case notes entered by the approving manager to explain the:

  • decision for approval;
  • parameters of approval; and/or
  • extent to which a policy is being waived.