Case Notes: Best Practices

Keep these ideas in mind to create the best case notes possible.

Who Reads Case Notes?

Many different people have access to and read case notes. It is important that case notes be written so that anyone reading the case note understands the actions taken by the worker and what information was used in making the decision. Your case notes may be accessed by workers at OKDHSLive! to answer customer questions. Supervisors and auditors may review your case notes.

Be sure to write your case notes so that they read professionally and accurately. Don’t use texting spellings or abbreviations or develop your own codes. Use only the abbreviations and acronyms found in the Common Abbreviations and Acronyms in Case Notes list. Include only facts in your case notes; avoid opinions. Case notes may be read in a court case. Think about what you are writing before entering it into case notes.

When Should I Enter Case Notes?

FACS case notes summarize information that was entered in the various tabs during interviews, case reviews, and when there are changes reported to the case.

Enter FACS Case Notes at the time of the interview

Case notes are entered during the interview as you enter information in each tab in the Interview section. The documentation should correlate with the information found in that particular FACS tab.

Enter FACS Case Notes when the case is reviewed or updated

Case notes are entered for the Mid-Certification Renewal or other reviews as you enter each FACS tab to update the appropriate blocks for documentation. The information should correlate with information found in that particular FACS Tab as the worker completes the MCR.

Enter FACS Case Notes when changes are reported and acted upon

When changes are reported and acted upon, you will document the changes reported and the action taken in the FACS tab that most closely correlates to the type of case change being made. (For example, a rent increase making a change to the Shelter tab should have Shelter tab case note.)

As some changes affect multiple factors of benefit eligibility, there may be several different FACS case note entries for each change. This same method should be used for documenting the clearance of data exchange exceptions.

What Case Notes Must Do

  • Transmit a clear message
  • Inform and justify action taken on the case
  • Describe how eligibility, continuing eligibility, or ineligibility was determined, what verification was used, and how income was calculated.
  • Document who is and who is not included in the benefits and if not included, why they are not.
  • Record
    • All case actions taken and the reason for the action
    • Date any overpayment claim(s) were discovered and calculated, along with related circumstances surrounding the claim
    • Information if the client is participating in the Address Confidentiality Program (ACP) administered through the Oklahoma Attorney General’s office, if applicable
    • Date of any referral
    • All client contacts or contacts with other persons who provide information used to determine eligibility. Include the date of the contact, the person’s name, phone number, and specific information you were given

Do not include confidential information or other comments that are not required to support actions taken by the worker to determine initial or continued eligibility.

Important!

Be sure to record significant dates other than the current day’s date in the case note. Once changes have been made in FACs you cannot retrieve the old information that was showing on the tabs.

Explain why the action was taken. It helps you know what is going on in the case without having to rely on your memory. It also helps anyone else who is currently involved with the case or becomes involved in the future to know what happened and why at a specific point in time.

Suggested information to document in the narrative portion of case notes:

  • How the client’s rights and responsibilities were explained and whether the client stated he or she understood them.
  • The date action is taken on the case
  • What action is taken
  • What benefits are affected
  • The program differences and what was used to make the decision for each program when the client has applied for or is receiving multiple benefits.
    • Document the income calculations used for SoonerCare (Medicaid) if different from food benefit and/or child care benefit income calculation and explain why some household members are included in some but not all benefits that the household is receiving.
  • The circumstances and reasons for any overpayment claims being established, including corrected income, household composition, etc. Include any information you used in screens, OCSS screens, or OIG information, as well as any action you might have taken in an effort to obtain correct household information such as dates and forms sent (for example, an 08AD092E (ADM-92)).

Avoid Oversimplifying and Entering Too Little Information

  • Too Little: John is paid $2100 monthly salary.
  • Better: Client’s spouse, John, receives full-time salary, paid $2100 on 15th of each month.
  • Even Better: Client’s spouse, John, receives a salary for 40 hours, working 8:30 a.m. – 4:30 p.m., Monday through Friday with no overtime, and is paid $2100 on the 15th of each month.

Which Case Notes are Most Scrutinized?

  • Earned Income
    • Projecting income?
    • What is representative?
    • Documenting it from client’s statement to case action
  • Child Support Payments Received and/or paid to others
  • Deprivation in TANF
  • Anything to do with TANF work
  • Child care plan of service, need factor, CS cooperation, etc.
  • Household Composition (Whose income is counted, etc.)

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