Policy Manual


Individualized Case Record      

Type: Procedure                 Category: Service Delivery                 Level: Community Care 

Parties: Community Care Employees and Contractees

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Supporting References: COA Standard RPM 7: Case Records

Parent Effective Date Approval Level Revision Dates Last Reviewed
N/A  5-1-1997  Executive Director  2/09  2-25-2009
Related Document Code Related Document Name Type

Procedure:  .

An individual service record will be maintained for all clients.Case records comply with all legal requirements and contain information necessary to provide services. Clients may add a statement to their case record and any response by service providers is added with the client's knowledge. The client will be afforded the opportunity to review and comment on such additions.  

 a.      Every entry must be specific, factual, and relevant.

b.       Every entry must be legible. (Determined by being readable by two other people)

c.       Every entry must be signed. Entries will also be signed and dated by the supervisor when appropriate.

d.       Every signature must be accompanied by title.

e.     Every entry must be dated.

f.     Every entry must be written in ink or typed and properly corrected as necessary.

g.     "Properly corrected" is interpreted to mean that errors are voided by crossing out the incorrect entry with one line, writing "void" ��next to the crossed out entry, and initialing and dating the correction.

h.      White-Out, Liquid Paper, or similar substances shall not be used on any form entered into the client record.

i.      The case record must have a unique client identifier (case number).