SERVICE / PROGRESS NOTES

SERVICE / PROGRESS NOTES

All services provided by The Ship Group Community Services will be documented by a client’s service / progress note and will become  part of the medical file for that individual client. Forms and formats for progress notes will be in compliance with the state standards as well as local Area Programs accepted format.

General rules regarding documentation include:

1. Only black ink will be used to make entries.

2. To correct errors, staff will mark through entries with a single line, initial, date, and enter correction

3. Each entry must be signed (full first and last name at minimum), dated (day, month and year) and authenticated by title.

4. White out may not be used on any notes for service records.

5. Services/progress notes must not contain names of any client other than service recipient.

6. All documentation must follow specific guidelines according to service, and must contain complete and objective information relating to client progress, including: 

• Date of service, duration of service, task performance(goals), description of intervention/activity, effectiveness, Medicaid/Record #, all notes are documented daily (and within 24 hours of services rendered)
• Signature of workers, credentials, degree or license number, or position title.
• Only abbreviations, which have been approved and are listed on the The Ship Group Community Services abbreviation list, may be used.

*Electronic Records Note: Service Notes are reviewed daily and printed within five business days for filing in the permanent record. In the event of an external audit in which Service Notes are not found in the record, auditors may be provided access to view the electronic record. Personnel with medical record duties maintain responsibility for filing these documents in the master client record according to agency and DHHS Records Management and Documentation Manual. Electronic medical records will continue to be monitored daily for new clinical documentation submission. 

Service/Progress notes are confidential and privileged information and must be treated as such at all times, this means lock it away.