109-2          RECOMMENDATIONS FOR DOCUMENTATION

Clear and concise documentation is always beneficial.  When documenting, staff must always:

1. •     Be factual; address only facts, and do not include any personal opinions or judgments.
     
     

   • Be specific; avoid vague, general, or ambiguous statements, instead provide exact and accurate information and details.
     
     

   • Be objective; make sure notes are unbiased and without subjectivity.
     
     

   • Be clear; dates, words, actions, and time frames must be clear and to the point.
     

The following tips may also help staff write understandable and succinct case notes:

1. •     Do not write anything that would surprise the client or would be uncomfortable to share with the client. Case notes are a record of the client’s situation. Therefore, it should reflect information that the caseworker and client have discussed.  Clients should never be surprised by what is in the case note.  If the case note would be uncomfortable to share with the client, staff should consider writing in a different way.
     
     

   • The case note must be understandable to the reader. It must provide a clear picture of the eligibility decision, what was done, and the reason. Refer to MS 109-6 and MS 109-8 for more information on using the CANO Case Notes Desk Guide and CANO Case Notes templates.
     
     

   • Remember that case notes may be viewed for purposes other than eligibility determination. It may be viewed by case reviewers, hearing representatives and officers, attorneys, judges, and other State officials.