Policy Manual


Service Documentation      

Type: Procedure                 Category: Service Delivery                 Level: Community Care 

Parties: Community Care Employees and Contractees

Printer Friendly Version: http://apps.comcareme.org/policymanual/default.aspx?code=3.MEP.2&nonav=yes

Supporting References: COA Standards RPM 7.02, 7.04, 7.05

Parent Effective Date Approval Level Revision Dates Last Reviewed
N/A  5-1-1997  Executive Director  10/08; 4/10  4-21-2010
Related Document Code Related Document Name Type
3.ME.11 Service Documentation Policy

Procedure:  .

1.      All documents or entries in the client record should minimally include the client's name, case number, date, and writer's signature and title.


2.      All direct service employees and supervisors will have internet access from home in order to facilitate the documentation of services to client records.


3.      All documents or entries in the client record should be legible, completed, dated, and signed by the person making the entry, written in ink or typed, and properly corrected as necessary.

4.      "Properly" corrected means 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.

5.      White-Out shall not be used to correct errors in client records.

6.      All documentation included in the client's case record helps serve as a basis for the planning, implementation, and continuity of the service program, and as a means of communication among the professionals who may contribute to the client's services.

7.      It will be the responsibility of the Clinical Supervisor to ensure that appropriate records are maintained on each client receiving services from his/her service providers and program.

8.      All employees, contractees, student interns, and consultants shall document all service provided to clients in a timely, accurate, and orderly fashion. "Timely" for this purpose means is within 48 hours of service. This documentation will include progress towards service plan goals as well as other interactions that may be pertinent to the service needs of the client.