7005 Documentation | APS-5500-MANUAL
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Georgia Division of Aging Services |
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Chapter: |
7000 TERF Case Management |
Effective Date: |
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Section Title: |
Documentation |
Reviewed or Updated in: |
MT 2021-01 |
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Section Number: |
7005 |
Previous Update: |
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Summary Statement
The Temporary Emergency Respite Fund (TERF) Case Management staff shall enter into the client’s case record written documentation describing observations, statements, findings, actions, activities and contacts with or on behalf of the client receiving TERF Case Management services
Basic Considerations
TERF Case Management staff will adhere to Adult Protective Services (APS) established policy of entering all electronic documentation as complete within 10 calendar days of the activity in the DAS Data System (DDS).
TERF Case Management staff will also adhere to APS' guidelines regarding maintaining physical and electronic records. Refer to Chapter 3 – Section 3012: Documentation of this Policy Manual
Requirements
Documentation includes:
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Information that is clear, factual and complete within 10 calendar days of documented action.
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Information regarding referrals and collateral contacted on behalf of the client.
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Information describing the social, physical and mental status of the adult.
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Statements and actions by the client, caregiver, service providers and collateral contacts that are relevant to the service provision, risk reduction and case management.
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demonstrate the need for and continuity of services;
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evaluate adherence to policies and procedures; and
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take appropriate actions based on the recorded evidence
Procedures
All actions are documented in the electronic case record shall contain:
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Date of contact;
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Type of activity (telephone contact, home visit, etc.);
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Time spent on activity
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Who was involved (i.e. name, title, relation to client of person contacted) and whether the client was seen;
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The purpose of the contact;
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Significant information and/or observations;
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Assessment related to the progress toward the case plan goals;
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The result of the contact and plans for follow-up contact.
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Any documents completed or obtained on behalf of the client as a part of ongoing service provisions will be uploaded into the electronic case record.
| Group contacts such as family meetings, Multi-disciplinary Meetings (MDT), facility care planning sessions, etc. can be documented in one note. All other contacts involving multiple participants must be documented as separate notes. |
A physical record will also be kept and contain any documents with original signatures and any legal documents. (Refer to 3012 Documentation of this manual for additional policy and procedure related to documentation and record keeping.)
Case Closure/Termination
The reason for case closure/termination must be recorded in the electronic record. The case closure/termination will be documented in the Justification Statement. The Justification statement shall include a brief but clear statement identifying:
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Client’s victimization
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Initial need/purpose for TERF Case Management services;
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Services established to help client achieve independence and stability in the community;
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Reasons why services are no longer needed including client’s current risk of victimization.
Once the case closure/need for termination has been documented, the case shall be submitted for approval by the supervisor.
Supervisor must indicate in the record that they concur with the reasons for case closure. Non-concurrence by the Supervisor will result in the case remaining open. Guidance will be given to the case manager indicating what additional actions need to be taken before concurrence can occur.
Supervisors have 5 calendar days to complete these actions.