Client contact and progress notes
The contact/progress note is more than the sum of the data elements that are required. The heart of the contact/progress note relates to the narrative. The note should answer the following primary questions to ensure good communication and billing support:
- Which of the MH-TCM four core service components (assessment, planning, referral and linkage, monitoring and coordination) was being provided?
- What goal/s or objective/s was/were being addressed?
- What was the service provided, what did the case manager do?
- What was the client’s respond to the service?
- What is the plan for the next contact?
Any significant observation of the client’s situation or condition should also be included. This should include any situation, information, or conditions that are not necessarily related to planned services, but that are important or out of the ordinary e.g. major news in client’s life, changes of behavior). These will not be present in every contact/note.
Often during a contact a case manager will be providing more than one case management service. Each service should be documented.