RHB 3040 Case Note Format:
Consumer’s Name: (consumer’s name)
Date of Contact: (date of contact with consumer or other person relevant to the case- physician, service provider, etc.)
Method of Contact: (phone call, appointment, assessment or report received)
Case Note Comments:
1) Objective (not subjective) review of event.
a. Consumer called and reported (unless you know something to be true through observation or documentation, the event is “reported” and is only hearsay) he walked off the assessment due to new pain in his right shoulder.
2) Justified reaction to contact.
a. CM informed consumer about agency policy regarding the completion of agreed upon assessments.
3) Outcome of contact.
a. Consumer agreed to call physician immediately to discuss pain and potential physical limitations not previously documented.
4) Next Steps (plan of next steps for the consumer and CM and deadlines)
a. Consumer will call physical today (date) and request an appointment to discuss new pain.
b. Consumer will call CM with the date of the scheduled appointment.
c. Consumer will meet with CM after the appointment to discuss any possible new physical limitations and how they might impact the current plan.
Case Notes are essential to document what is happening in the case for review requirements, funding agency requirements, and to assist the CM in knowing what is going on with each consumer. All information should be objective (not subjective). If a CM has not spoken to the consumer in a few weeks or months, it is easy to look at the last case note to see what was the last thing that happened and what were the next steps to occur. If those next steps did not occur, the CM has a place to start to follow up on why those steps did not occur.
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RHB3040CaseNoteFormat1.docx
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