Appendix 202-B Documentation Guidelines

Georgia State Seal

Georgia Division of Aging Services
Home and Community-Based Services Manual

Chapter:

200

Effective Date:

Section Title:

Documentation Guidelines

Reviewed or Updated in:

MT 2021-09

Section Number:

Appendix 202-B

Previous Update:

Documentation is the formal record of the agency’s work and proves that staff conducted appropriate activities on behalf of the individual. Each case note is the narrative that describes the background/history and activities with or on behalf of the individual and provides an historical and chronological record of interaction with the individual and his/her community. Proper documentation adds credibility to case management decisions or interventions recommended on behalf of the individual. Staff should write case notes in such a manner that any person (including supervision or the Court) will understand exactly what transpired during the agency’s work with the individual. Good documentation helps avoid liability and is instrumental in promoting excellent quality assurance practices. The bottom line is this: if it is not documented, it did not occur.

The New York State Society for Clinical Social Work lists the following purposes of documentation (with paraphrasing):

  1. To document professional work

  2. To serve as the basis for organization and continuity of care

  3. To serve as the basis for subsequent continuity of care by recording for use by other practitioners who may serve the individual in the future

  4. To protect against lawsuits and complaints and to aid in defending effectively against such lawsuits or complaints

  5. To comply with legal, regulatory, and institutional requirements

  6. To facilitate quality assurance and utilization review

  7. To facilitate coordination of professional efforts by fostering communication and collaboration between agencies serving the individual

Examples of topics to be included in a case note include:

  • Presence of a Legal Guardian

  • Needs, preferences, or values of the individual

  • Cultural awareness

  • Options discussed with the individual

  • Referrals made on behalf of the individual

  • Education provided to the individual

  • Advocacy on behalf of the individual

The following guidelines will help to ensure that documentation is appropriate and professional:

  1. Case notes should be written in a factual, objective manner. Objective language can be measured, counted, and seen by more than one person. Two people reading the note would have the same understanding of the situation. Examples of information include:

    1. Client activities observed by staff or reported by the client (“The Case Manager saw Mrs. Smith crying and clenching her fists.”)

    2. Agency actions (“The agency has suspended Mrs. Smith’s service for two weeks because she was admitted to the hospital on 02/01/2014.”)

    3. Information from official records or documents (“The report from Dr. Jones dated 08/13/2014 stated that Mrs. Smith has hypertension and diabetes.”)

    4. Descriptions of circumstances (“Mrs. Smith stated it is important to her to return to her home to care for her pet cat.”)

  2. Staff must avoid subjective, judgmental, or vague language

  3. Staff must avoid labels such as ‘alcoholic’, ‘schizophrenic’, incompetent’, ‘incapacitated’ or ‘mentally retarded’ unless a certified or licensed professional has documented such a diagnosis

  4. Staff must refrain from including personal opinions or perceptions unless clearly labeled as such and factual justification for the opinion is included

The chart below provides examples of poor notes and appropriate notes:

Poor Note Objective Note

Mrs. Smith will obtain adequate housing.

Mrs. Smith will obtain housing that has running water, electricity, and is accessible for her wheelchair.

Mrs. Smith’s family is dysfunctional.

I observed Mrs. Smith, her husband, and her daughter screaming at one another during the face to face meeting.

Mrs. Smith was drunk.

I observed Mrs. Smith having slurred speech, staggered gait, and her breath smelled of alcohol.

Mrs. Smith is an alcoholic.

Mrs. Smith’s daughter said, “It is embarrassing to have an alcoholic for a mother.”

Mrs. Smith refused services.

Mrs. Smith said, “Leave me alone” and shut the door.

Mrs. Smith could not sit up and obviously needs 24-hour care.

I saw Mrs. Smith struggle to pull herself to a sitting position for our meeting.

Mrs. Smith was rude and unresponsive during my interview.

Mrs. Smith stated she had no comment when asked about whether she wanted to return home from the hospital. After I asked her more questions, she asked me to leave her room and not bother her again.

Examples of subjective, vague terms include:

  • Abusive

  • Adequate

  • Angry

  • Apparently

  • Appeared

  • Appropriate

  • As soon as possible

  • Clean/dirty

  • Cluttered

  • Good/poor

  • Happy/sad

  • Healthy

  • Hostile

  • Hyper

  • Hysterical

  • Immediately

  • Loud

  • Incompetent

  • Incapable

  • Messy

  • Neat

  • Neglectful

  • Nervous

  • Nurturing

  • Obviously

  • Offensive

  • Physical

  • Proper

  • Quality

  • Regular

  • Seems to be

  • Suitable

  • Stable

  • Unmotivated

  • Upset

  • Tidy

  • Well cared for

The New York State Society for Clinical Social Work “Clinical Documentation and Recordkeeping” includes the following elements of good documentation:

  1. Provides relevant information in appropriate detail

  2. Is organized with logical progression

  3. Is thoughtful, reflecting the application of professional knowledge, skills, and judgment in the services provided

  4. Is appropriately concise

  5. Uses relevant direct quotes from the individual and other sources identified as such by utilizing quotation marks

  6. Distinguishes clearly between facts, observations, hard data, and opinions

  7. States the source(s) of the facts, observations, hard data, opinions, and other information being relied upon, and provides an assessment of the reliability of that material

  8. Is internally consistent