1. Documentation of Services Tip Sheet
Progress Notes
Documentation of Services Tip Sheet
Washtenaw County Community Mental Health

2. Overview
Keeping track of what is happening in the life and services of the person you support requires keeping records.
While providing direct services may be the core of your responsibility, effective documentation tracks and details the needs, services, goals, and progress of the person served.
The quality of your documentation also impacts decisions that are made about the services the person is receiving, ensures all members of the care team communicate important details about those services and ultimately affects the person’s quality of life.
Washtenaw County Community Mental Health

3. Overview, Continued
Any service paid for by state/federal funding can/will be audited. Centers for Medicare and Medicaid Services (federal) and Michigan Department of Health and Human Services (state) will require proof a specific service occurred when auditing.
Documentation (progress note, daily log) is a way to show:
What service was provided (paid for)
How long a service/shift was provided
By who a service was provided (must be an appropriately trained/credentialed staff)
If this information is not fully provided, money paid out for that service will be taken back.
Detailed documentation is essential for quality care, good communication, and to prove state/federally funded services.
Washtenaw County Community Mental Health

4. Why is documenting services important?
Progress notes are the central aspect of a person’s health record; a place where staff document the care they deliver
All relevant details should be documented for a person’s diagnosis, clinical state, and daily activities that occurred during a shift
Demonstrates medical necessity: justifies why the individual needs the services
Provides a foundation for future services and for alternate approaches
Compliance with insurance company requirements: clearly documents encounters/proves services provided for billing purposes
Washtenaw County Community Mental Health

5. Why is documenting services important? Continued
Reduces duplication of services provided between co-workers
Can be subpoenaed and read in Court of Law
Used to prove services occurred for audit purposes
Reminds all of what has previously occurred with the person
Tracks progress with goals
Aids communication between co-workers
When appropriate, aids communication with natural supports and family members
Washtenaw County Community Mental Health

6. What gets documented?
What you actually did: attended appointment, cooked with client, worked on sensory goal, administered meds, prompted to complete household chores, etc.
Progress on treatment plan (IPOS) goals
Observable facts
Information the person themselves state
Unusual incidents and accidents involving the person
Communication with other service providers
The health status of the person, including current health planning and management, and medication management
Washtenaw County Community Mental Health

7. What does not get documented/what you should not include?
Opinions, judgments, or unproved statements
Information about another client
Slang/jargon
Abbreviations
Washtenaw County Community Mental Health

8. Helpful Tips If you didn’t document it, it didn’t occur
Notes must be accurate, easy to read, complete and timely
Write for an audience
Notes should be connected to the client’s individualized treatment plan
Do not use white out or scribble anything out
If you make a mistake, cross it out and put your initials by it
Always include the following information: date, times, client’s name and signature of staff
Washtenaw County Community Mental Health

9. Example: Residential Setting
Washtenaw County Community Mental Health

10. Example: Non-Residential Setting
Washtenaw County Community Mental Health

11. Reminders
Residential Setting= non-licensed CLS settings and licensed residential settings
Non-residential settings= skill building, supported employment, ABA, respite, etc.
Do not combine multiple clients on one progress note
Include client’s name and ID #
Include the times that services were provided to client (include “AM/PM)
Check boxes are not enough- always add staff observations/goals worked on
Always sign-off and date the progress note
Washtenaw County Community Mental Health