basics 2013 –part 1 (pd 1 - cloud object storage | store & …€¦ · · 2016-03-11other...

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1Service Notes Basics 2013 – Part 1 (PD)

Course Number: 014‐04‐01

This webcast includes spoken narration.

To adjust the volume, use the controls at the bottom of the screen. While viewing this webcast, there is a pause and reverse button that can be used throughout the presentation.

The written version of the narration appears to the right of the screen.



Certificates of Achievement will be available to SCs and SC Supervisors after completing all course requirements. Please view and then save or print your certificate in order to receive credit for this course.

For SCs and SC Supervisors, course requirements include successful completion of a pre‐test and post‐test.



This webcast contains information that will help you write organized, effective and complete service notes.

We’ll talk about the purpose of documentation and service notes.

What we present will demonstrate clear connections between the responsibilities you perform as supports coordinators and recording your actions in service notes.

We’ll review how service notes are constructed step by step, allowing you to see ways to organize content more efficiently.

We’ll talk about the essentials that you must consider each time you write a service note.

After watching the webcast, you’ll be able to describe basic practices for service notes.

Finally, I’ll talk about resources that are available to learn more about documentation.



Before we talk about service notes, let’s review what is meant by “documentation.”

Documentation is a way of capturing information in an organized way and preserving it for the purpose of communicating it from one person to another. It’s a broad term that includes many different methods. As a supports coordinator, you’re familiar with two common methods – paper and electronic records. In the ODP system, some types of records are only kept electronically.

Documentation is a necessary and important part of Supports Coordinator’s work.

But…What are the purposes of documentation?



Documentation is a record of the actions taken with someone or on their behalf.

It provides the perspective of what has occurred over time, which can help to identify trends or issues.

For example, looking at a continuous record of documentation allows the reader to see what is working and needs to continue, or what is not working and needs to change.

Documentation can be an important way to record progress and measure whether plans are effective in achieving desired results.

When things in a person’s life are changing – for example, new supports or staff ‐ documentation can provide continuity. If clear documentation is available and a new staff person reviews it, he or she will be able to minimize any disruption to the person receiving services.

In addition, documentation is necessary to evaluate whether federal, state or local requirements are being met.

Documentation is used as a method to justify billing and payment for services.

From the Supports Coordinator’s perspective, the primary documentation responsibilities are related to the Individual Support Plan, SC monitoring, and the focus of this webcast: service notes.



These are some examples of the usefulness of information in service notes.

They can contain important information about how supports and services for health, welfare, and individual priorities outlined in the ISP are being implemented in the person’s everyday life.

Service notes can be an important part of the big picture of developing ISPs and outcomes and for measuring progress.

Services notes are routinely reviewed during legal proceedings, for example, when an individual exercises right to an appeal.



To understand why SCs write service notes, think about the SC’s primary functions. The Service Definition defines each of the Supports Coordinator’s functions:

Locating services and supports consists of assistance to the person and his or her family in linking, arranging for, and obtaining services specified in an Individual Support Plan (ISP).

Coordinating consists of development and ongoing management of the ISP in cooperation with the person and team.

Monitoring consists of ongoing contact with the person, family, and others providing paid and non‐paid supports to ensure services are implemented as outlined in the ISP.



Let’s make the connection between the Supports Coordinator’s roles and how documentation can support them.

In your role as SC, you locate services for the people you support: paid supports in the ODP system and those available in the community. You look for opportunities to make the most of unpaid supports, so the person can have the opportunity to foster meaningful relationships and meet new people. Service notes provide the detail of what’s happening in a person’s everyday life that can be crucial to locating the optimal services and supports. When thinking about unpaid supports in particular, the detail about who is important in a person’s life ‐ and why – is often found in the descriptions of the interactions among people that you document in service notes.

SCs are responsible to ensure supports and services work together, don’t conflict, and don’t duplicate each other – this is the SC role of coordinating of services and supports. Service notes can provide a “birds‐eye” perspective of how well services and supports coordinate as outlined in the ISP – or if adjustments need to be made. They also help you as the SC to measure your effectiveness in coordinating services.

Let’s say you are the SC for a person facing significant life changes, for example, graduating from school, starting a new job, or moving into a Lifesharing home. You want to make sure that all the parts of a person’s life – what’s new and what’s already in place – work well together. Your service notes can provide important information on all the aspects of the person’s life that need to be coordinated.

As it pertains to responsibilities of supports coordination, monitoring encompasses both SC monitoring as well as less formal SC observations.

We’ve said that one role of documentation is to provide perspective over time on what’s working and what needs to change. Reviewing service notes can help you and the team have more informed discussions about effectiveness of services in meeting health and welfare needs as well as promoting personal priorities. Like I’ve mentioned already, the detail is crucial: documentation in service notes contains the detail over time that teams rely on to answer questions about service effectiveness.



This training is designed to help you, as the writer, to improve skills and proficiency in writing service notes. But as you listen, keep in mind that there is an audience for what you write. Improving your skills in writing service notes has another purpose in mind: to communicate useful and meaningful information to those who read and use your service notes. Much of the information in this webcast will be useful to you – but it is also intended to benefit those who read service notes. An example of this is monitoring of Administrative Entities and monitoring of Supports Coordination Organizations. Clear, well‐written service notes will support those activities.

Keep in mind that service notes are only recorded in the Home and Community Services Information System, or HCSIS – the sole system used to capture this important information.



As we continue, we’ll talk about three main aspects of service notes:

1. What should be included in content and how to organize the information

2. Elements that support well‐written and easy to understand communication, and

3. Accepted practices in documenting service notes – such as timeliness and coordination with other documentation.

We’ll start by discussing the content of service notes – the basics that should be included in every service note.



You may already be in the practice of beginning a service note with a brief phrase – two or three words that describe the nature of the contact. This is not a long description, but only a few words that help you and the reader get a quick sense of the context.

Descriptive phrases helps to formulate your thought process.

The phrase helps readers understand the context of the content that follows.

These phrases can also be helpful when searching for service notes by the type of activity that was completed. So, descriptive phrases can make it easier for you – and others ‐ to locate notes that address specific activities.



Next, keep in mind the four W’s: where, when, who, and what. Although this order of questions is not required, it is recommended, in order to help organize the note so it’s easier to write and better understood by readers.



Okay, so after the short phrase which describes the nature of the event, write the location where the activity occurred. This is a more specific location than the options that appear on the HCSIS entry screen like home and community. This helps readers form a more complete picture of the situation and environment in their mind.

If you identify that the note reflects a phone call, it’s not necessary to include this location detail.



Including the date of the event is easy, when entering notes in HCSIS, the system requires that you enter this information. So, there’s no need to also include the date in the content of the note itself. The information included in the HCSIS entry fields online is sufficient to describe the “when.”



Next, write who was involved in the contact.

Identify the person first and then identify others receiving service by first name and last initial only, to preserve their confidentiality. In addition, list all who attended by full name, their title or relationship, and agency affiliation.

If others were invited to the meeting but were unable to attend, it can be helpful to note this as well.

Please note: if you are writing a service note to reflect an ISP meeting, you do not need to also record attendance in the note. The ISP signature page is sufficient to capture this information.



“What” describes the event that took place.

It is a summary that expands on the one or two words you used to describe the nature of the contact at the beginning of the note. Clearly state what happened so that other interested people who were not present can understand what took place.

To write this part of the note, begin with a description of the purpose of the event, including what participants wanted to accomplish. This helps the reader to further understand context. In the note, include the primary issues that participants planned to discuss or take action on.

After the primary issue(s) and tasks to be accomplished are outlined, describe what was actually discussed and what actions took place during the contact.

At this point, we know where and when the contact took place, who participated, the reason why it happened, and what occurred or was discussed in regard to the purpose of the contact. There is still more that needs to be added to the note, but before doing that, we’ll illustrate these points with an example.



This example and the characters in it are fictional.

Bert is in his late 30s and shares an apartment with Bob S. Bert receives support from L.I.F.E Services, Inc. Bert receives an average of 6 hours of support per week from L.I.F.E. to assist with paying bills, shopping, dealing with his landlord in regard to apartment issues – primarily when things need to be repaired or maintained – and occasional support from on call staff. (Bert has sometimes gotten confused when out in the community at night.) Melinda Frei is his staff support person from L.I.F.E.

Bert is close to his sister‐in‐law, MargeAnn, who is an important part of his life. Bert and Bob’s upstairs neighbor, Billie Nieman, has become a good friend of the gentlemen and invites them to dinner, weekend services, and other community events.

Bert has a tendency to spend too much time by himself in his apartment and needs support to stay in touch with family and friends and to make sure he’s getting out of his apartment now and then. He also needs someone to call if he becomes anxious while out. He has kept his job in a supermarket for almost two years and has also managed to spend less on video games and save some money. Bert is proud of what he’s accomplished. And, he’s more confident and self‐reliant than he was even a year or two ago. Lately, he has been talking about being less dependent on services – like his roommate Bob, who used to receive support from L.I.F.E. but is now independent. Some team members express concern about Bert’s desire to be completely independent, but do understand his desire for privacy.

On September 9, 2011, Bert and his team met at his apartment for a quarterly service review for supports provided by L.I.F.E. Bert told everyone in advance that he wanted to talk about having more privacy in his life and doing more things independently during this meeting. Sue Smart, Bert’s job coach, was invited to the meeting even though her supports are fading. Josh Bildure is Bert’s Supports Coordinator.



Josh kept notes during the meeting and was ready to write a service note the next morning when he returned to the office. The date and time were chosen from the drop downs on the HCSIS entry screen, and he began the note with a short phrase that described the nature of the meeting and then listed those present.



Then Josh outlined the current issues. He briefly confirmed that the topic at hand – a quarterly service review which shows that services are in line with what was written in the ISP.

Next, Josh wrote a summary of the discussion that followed the review – specifically, Bert’s request for fewer support hours. He includes Bert’s reasons: he wants more privacy in his life. He’s managed to meet his outcomes of spending less and saving money, and has shown dependability and responsibility by staying at his job for two years.

So far, Josh has outlined the purpose of the meeting, clearly and succinctly; identified a current issue that needs to be discussed, and provided context for the issue. The reader is now prepared to follow the discussion.

The last paragraph on this slide is Josh’s synopsis of the team’s discussion and concerns.



Now we know where and why the team met, who was there, and what they discussed. But describing when, where, who and what do not complete the note. What happened after that? What plan did the team make?

Service notes also need to include the expected next steps that will occur as the result of the activity. Identifying this information focuses participants on actions that need to occur to resolve issues and make progress toward outcomes and it allows everyone to know what is expected of them.



After describing who, what, when, where – service notes also need to capture what was decided and the next steps, including:

Actions that will occur, and the reasons for them.

Who will complete the actions and how often will they occur.

In addition, service notes should include information that connects to the ISP. For example, how do the decisions of Bert’s team affect the plan?

Finally, as a contact is finishing up, most SCs think, “when will we need to get together again?” or, “When is the next contact?” This information should be included in the note as well.



This is the follow up that Josh included in his service note.

It includes all the actions that will occur and who is responsible.

It ends with a clear description of what is changing, and links to the ISP. Finally, Josh includes a timeframe for the next actions to occur – the team will meet more frequently to monitor how things are going.



Next we’ll talk about essential elements of service notes.

As we talk about these elements, we’re not referring to personal preference or becoming a best‐selling author. Instead, they refer to:

The basic rules of writing:

‐ Using person‐centered language that is objective ‐ and how to appropriately include subjective information in service notes; also,

‐Writing clearly and concisely, and

‐Writing in a way that conveys a respectful attitude toward individuals receiving supports coordination as well as the families of that individual.



One challenge is how and when to include information on disability in service notes. First, it is not necessary to identify the person’s disability in every service note. However, when it is important to understanding the content of the service note, use “People First” language that identifies the person first and then the disability.

How you portray the person in your service notes can have an impact on how others perceive him or her, because:

‐ A disability represents only one of many characteristics of the person, and

‐ Putting the person before the disability is respectful, since it sends the message that the person is a unique individual and not a condition or set of limitations.

‐ Disability is a natural human condition and how we describe its impact has a great influence on how others treat and respond to people with disabilities.

People First language describes a disability as something a person has, not who the person is, and puts the person before the disability – both in terms of how to speak (for example, a person with…”) and in terms of how we think about people.



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Okay, here are some examples of how to use People‐First language. When it’s necessary to include information about disability in a service note, using this approach encourages readers to have an attitude of respect.

There is more information on People‐First language at the end of the webcast.

Service Notes Basics 2013 – Part 1 (PD)


In service notes, describe people from a strengths‐based viewpoint. Whenever possible, include the person’s abilities and contributions.

Listen for and record what people say are the person’s positive attributes.

Look for opportunities to focus on what the person has accomplished or does well.

Including strength‐based descriptions, attributes and accomplishments can help foster a more positive attitude about the person.



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Next, we’ll talk about objective writing and subjective content.

Objective writing describes what was discussed or what occurred – what was seen, heard, or directly observed. Using objective writing means that facts are presented free of assumptions and opinions. Objective writing creates a strong, accurate and reliable record of what actually occurred.

Subjective information is based on reactions, assumptions, opinions, and feelings that can be influenced by personal bias, values, or beliefs. Subjective information may or may not be connected to facts. Service Notes should not reflect the feelings or opinions of the SC, especially any negative feelings or reactions toward any person or situation. However, the subjective opinions of others – if documented appropriately – can be helpful in understanding the situation.



Writing objectively means focusing on observations – what is seen, heard, even smelled or touched.

I might describe Tom’s behavior as “anxious” and know exactly what I meant. However, would you know what I meant or observed?

Instead, if I described Tom’s actions and what he said, I’m now using objective language that is less likely to be misunderstood. Not using words like “anxious” also removes the subjective impressions readers might attach to it, including negative feelings.

Including a description of Tom’s actions and Simona’s reaction and allow the reader to know what occurred, free from bias or feelings.

Think about the importance of writing objectively. If a support professional only had a word like “anxious” to consider, what might he or she conclude? What might the implications be for Tom? However, knowing that Tom’s actions express a normal worry for his sister allow readers to understand him better and not come to the wrong conclusions.



Objective writing means removing judgments and assumptions and recording what was observed ‐use your eyes and your ears. Document what you heard, what you saw, what happened.

In this example, the subjective note conveys judgmental conclusions – and the conclusions may or may not be correct.

Now look at the objective version. It’s more descriptive and is free from conclusions that are based on assumptions – there may be many reasons why Fred’s clothing was stained and wrinkled and his hair and face were not clean. For example, perhaps Fred isn’t aware of the impression he is making, or it’s just not important to him.

It’s important to note here that recording objective information free from unproven conclusions does not mean that that’s all the SC should do. In this case, the SC added a note that helped explain the reasons for her observations: Fred has been sick and hasn’t felt like doing laundry or taking a shower. Including the objective information allows a reader to know what occurred.



Subjective content does have a place in service notes, as long as it is handled carefully. Distinguish between your own subjective opinions and feelings and that of others. Including the subjective comments of others can be useful in clarifying how someone else feels and gives insight into his or her motives and reasons.

When you hear the subjective opinions of others, it’s an opportunity to gather more information. If you ask the person the reasons why he or she has a certain opinion or has made an assumption, you’ll then be able to include these in the service note later. Most people will explain their reasons and give their own more objective reasons for feeling the way they do. For example, if Mary’s mother tells you that she doesn’t think Mary likes her job, it’s an opportunity to learn more about what’s happening in regard to her job. Her mother may give you her own objective observations of Mary’s actions that lead her to the conclusion.



When including subjective opinions of others in a service note, make sure to cite who supplied the information and place their words in quotes. Include the questions you asked and the additional information you received that sheds light on the subjective information.



Supports Coordinators should not include their own subjective opinions, feelings or reactions in service notes.

One risk of writing subjective notes is that your belief about a situation could be incorrect.

Another risk of writing subjective notes is that they can be judgmental. SCs should avoid terms and descriptions that reflect their personal values, or feelings.

The first statement is subjective.

To restate it in objective terms, think about the opinion/feeling you want to document. Then think about what the opinion/feeling is based on ‐ why do you feel the way you do? What did you see or hear that prompted your feeling or reaction? Find the objective reasons for your reaction or opinion and write these in the note.



On the slide are six statements. Two of them are objective and four are subjective. Take a moment to read each one and decide which are objective vs. subjective.



The first sentence – “Sean behaved badly at the dentist today” is subjective. The word “badly” is a word that means different things to different people and does not objectively describe what Sean did. This term is also judgmental.

Next, Jim’s statement is objective. Although “tired” is a subjective word, this is how Jim says he feels. Therefore, it’s an objective report of what Jim stated about his own well‐being with his reason for feeling that way.

Randy’s feelings about lunch are the speaker’s subjective impressions. There could be many reasons why Randy had seconds besides liking the lasagna – perhaps he missed breakfast, or was trying to please the cook. Adding that he liked it is an assumption on the part of the speaker. Note that the SC correctly placed this statement in quotes.

Without knowing any of the reasons why Candy might be indicating that she likes the new staff person, the statement can only be considered someone’s subjective impression of Candy’s actions.

The next statement ‐ I saw Justine hit her brother on the head – is a clear objective statement of observation.

The final statement ‐ Jerry is not taking good care of his cat – his apartment really smells – is subjective. It contains an assumption of the writer that, because of the odor, Jerry is not a good pet owner. The statement is also imprecise. What did the writer smell that led to the conclusion? What other observations did he or she make?



Clear writing is straightforward and easy to understand. Use words that you are reasonably certain the reader will understand. When in doubt, use a simpler word than you think you need.

Ask, would someone who doesn’t know the person, situation, or service system understand the note?

Avoid words that can be interpreted differently by different readers. Instead of simply saying Karen was happy – give the reader a few words that demonstrate how she showed her happiness. When relaying information, use words that are descriptive and less open to interpretation. In the example, an “odor” in the kitchen is open to various interpretations and does not help a reader understand what you observed or the implications. Is the odor from spoiled food? Is it a gas smell? And, where did it come from?

“Odor” is a word that means different things to different people. Descriptive language creates a shared understanding. Examples of other words that mean different things to different people are angry, depressed, and sad. Avoid using words that can be interpreted differently.

As you write service notes, ask yourself – “if someone else read my service note, would they clearly know what I observed?” And does it set the stage for the actions that occurred or what people did?



If an acronym is widely used and familiar to most of the people who may read your service note, it is acceptable to use. An example of a widely used acronym within our system is “ODP.” But, avoid using acronyms that are not commonly understood, unless they are spelled out the first time they are used in the service note. Each system has its own internally used abbreviations and acronyms. Sometimes people who work in a system become so accustomed to using these abbreviations that we forget that they are not necessarily meaningful to the rest of the world. Avoid using those acronyms or abbreviations that are unique to your agency because the potential audience for service notes is much larger.

A practice that will improve the clarity of your service notes is to re‐read what you wrote before submitting it. Are there points that you had to pause and re‐read to understand what you meant? If so – this is a good time to put on your editor’s cap and revise.



Concise writing means conveying meaning using as few words as possible – and using words and phrases that are precise and descriptive. For example, saying “John went on a community activity” may be brief, but it is vague and imprecise. Do you know what John did if I said, “John enjoyed a bluegrass concert with friends.” These two sentences are about the same length, but the second conveys a lot more meaning and insight into what John likes to do with friends.

There are several ways to practice writing concisely:

‐ Practice conveying meaning in as few words as possible. Strive for a balance between enough and too much information.

‐ For example, does the note tell a cohesive story but not provide unimportant details?

‐ Review the note and edit to eliminate information that doesn’t support the main points you need to make.

‐ Read the note out loud to yourself. When it becomes difficult to read, simplify the sentence.

‐ Use simple sentence structures. Avoid using long and compound sentences.



Service notes are to be written in complete, correct sentences and should not contain abbreviations like those used in text‐messaging.

Spelling is not everyone’s strong suit. Some people find it helpful to type a note in a word processing program to check spelling and grammar before entering the note in HCSIS.



There are many reasons for striving to improve the content of service notes:

What you write gives an impression of the person you support, the team and you. Writing respectfully portrays everyone in a positive, respectful way.

Writing objectively, clearly and concisely is vital for accuracy. Remember, your notes can be used for other purposes, such as legal proceedings – also, service notes are often referenced when ODP conducts monitoring of Administrative Entities and Supports Coordination Organizations. Notes must be written so as to justify the service you provide.

Service notes serve as a record of what has happened and therefore can influence what you or others do in the future. Therefore, it’s important that the descriptions be accurate and complete.



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Of the many reasons to practice good content and correct writing style – think about those who may read your note.

Any of these people listed on the slide may have occasion to read service notes. For example, service notes are often reviewed by ODP staff as part of their oversight role. Service notes may be used as evidence in legal action – and attorneys, judges, and other authorities may need to read them.

SCs should keep in mind that they are writing for a potentially broad audience of readers.



In the last section of this training, we’ll talk about some of the basic practices associated with service notes.



We’ll discuss the scope of activities that can and should be included in service notes.

We’ll review the importance of timeliness in completing service notes;

We’ll briefly cover the role of confidentiality when documenting service notes;

And finally, we’ll spend a little time discussing how to coordinate information in service notes with other documentation requirements.



When thinking about the activities that can be included in a the documentation of a service note, the key is looking at all that is involved in the activity. Note that we are talking about what you write in a service note, not tracking the time spent in an activity.

This includes the time it takes to:

Prepare for the contact. What things did you do before the contact that were necessary and relate directly to the purpose for the contact? Some examples include: ‐ Reviewing the last contact to ensure you have the details in mind to guide the discussion. ‐Making phone calls right before the contact to ensure everyone is still planning to participate and that they know what they’re expected to do.

Include the information that describes the contact: this the content of the service note that we discussed earlier – when, where, who, what, and the next steps are.

Include follow up that occurred immediately after the contact. For example, if the result of a meeting was that you would make a referral for an individual – and you completed the referral after returning to the office – that information is immediate follow up and can be included in the service note. Remember that HCSIS includes a feature that allows you to flag service notes for follow up.



It is important to complete service notes as soon as possible after the contact. That’s when you’re best able to remember all the details that occurred. The longer you wait, the less accurate your memory will be. Think back to the work you performed one week ago today. If you’re like most people, the details will already have gotten a little fuzzy.

And as we’ve said, a reasonable amount of detail will make the service note a better tool for making decisions later.

Also, waiting for two or three days can delay valuable information being available for other team members. Without all the information, the team may not be able to make the best possible decisions to support the individual.

Specific timeframes for completion of service notes are included in ODP Bulletin #00‐10‐06, Supports Coordination Services. Meeting these timeline standards will help you keep entry up to date and maximize the accuracy of your notes. Your SCO may have more rigorous timelines.



Okay, so: how do you keep track of notes when you’re out in the field? How do you track which notes you’ve entered and which you have yet to enter? How do you ensure that you manage time effectively so that you can meet or exceed deadlines for entry?

Everyone has his or her own system. The point is to have a system and to use it consistently. Some suggestions are on this slide.

Some SCs find it helpful to keep a notepad with them to write down important details during contacts – and cross the rough notes off the list when the service note is entered.

Other SCs find it important to build time to document into their schedules in order to meet entry timelines. If you know that you’re going to a meeting that will last a while and cover a broad range of topics, you can anticipate that you will need a little extra time to document it. It might be helpful to build the documentation time into your schedule so you can be sure you don’t run out of time when a deadline is approaching.

It’s also helpful to set goals for service note entry and track whether you’re meeting them – and to look at the reasons why. Could it be that I underestimate the time I need to document contacts? Could it be that I don’t have an organized way of tracking details and spend too much time trying to remember what happened? Once I begin to realize the reasons that keep me from meeting deadlines, I’m on the road to tackling them and becoming more efficient.



Health‐care related information is covered under the Health Insurance Portability and Accountability Act, or HIPAA. HIPAA provides for the security and uses of confidential information, including service notes. The system that SCs use to enter service notes is secure –but what about the methods you use to keep notes? Do you handle notes carefully and destroy them when notes are transferred into HCSIS?

The Pennsylvania Department of Public Welfare and each Administrative Entity have policies and procedures for confidentiality that comply with HIPAA standards that you must follow.

Much of the information that is gathered or learned from people and families is very personal in nature and not everything that is told to you has to be included in a service note. For example, if a person shares details of a recent date they had with their significant other, and there is nothing of concern with what they shared, you do not have to record those details in your note. Instead you may just report that they had a date and how it went in general. Another example is if a family member of a person on your caseload shares information about a situation they are dealing with that in no way affects the person receiving supports, you should not write about it. In this way, confidentiality protects the integrity and dignity of every individual.

And as we’ve discussed previously, the full name of other individuals receiving service should never be included in another person’s service note. First name and last initial of those other individuals is sufficient.



For every contact that an SC makes, he or she also enters a corresponding service note. It’s important to ensure that the service note clearly refers to the other activity – and where further details can be found – without duplicating every detail that can be found elsewhere. Service notes should highlight/summarize important points.

Examples are:

‐ Enter a corresponding service note after completing SC monitoring;

‐ Summarizing the main points of an ISP meeting;

‐ Noting an incident in a service note and referring to the incident itself for details.

There is no rule or formula for how much detail to include in a service note that refers to another activity that is more fully documented in another place. However, it’s important to include at least enough detail to give the reader a snapshot of the issue – and to clearly refer to a source document for more information. In the example on the screen, a reader would know the nature of the incident; that John was safe; and the incident number that would allow the reader to do further research.

Another example in which a service note could be brief is a reference to SC monitoring as shown in example number 2. The information included in the monitoring form needs to contain the detail to stand alone. The Service Note does not need to repeat the information documented in the monitoring form, but should include sufficient information to support the service provided.

The key here is that service notes need to be detailed where the detail is important, but should also be concise, and focused on the main issues.



These are the main points we’ve covered today. There is a printable version of this presentation where you found this webcast. If it would be helpful, you can take a copy of this slide and keep it handy for reference.



Here are some resources for further information.

ODP Bulletins, including Supports Coordination Services, are available on the PA Department of Public Welfare website. This bulletin contains specific information on service notes, including timelines for entry.

The HCSIS Learning Management System also contains tips for using service notes information.

ODP publishes a list of commonly used acronyms that can help make documentation easier. Please remember the caution not to over‐use acronyms, however.

Resources to learn more about People‐First Language – and related topics – are also available.



This webcast has been developed and produced by the Office of Developmental Programs Consulting System on behalf of the Pennsylvania Department of Public Welfare, Office of Developmental Programs.

Thank you for participating in this lesson.



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