Documentation is essential in assessing the effectiveness of service coordination activities. All contacts with or about the participant should be documented in the SHCN Information System (MOHSAIC) as soon as possible, but no longer than 10 business days after the date of the contact. This applies to all types of contact including phone calls, attempted phone calls, home visits, transition planning, making a referral or completing an assessment, etc. All documentation in the SHCN Information System is considered to be a legal record.

The seven basic components of documentation are:

• Contains a full and clear description of the contact,
• Factual, no opinions,
• Contains only relevant information,
• Objective,
• Concise but thorough,
• Describe the steps that have been taken, and
• Detail future steps/plans.

Other documentation requirements:  

• Documentation should be written in first person, using complete sentences or bullet style recording. Use proper grammar, spelling and punctuation.
• Use of the “Home Visit Template”, the “Monthly Contact Template” and Prior Authorization Template”, is required.
• Documentation should be comprehensive, justify staff actions, and include an action plan enabling others to intervene in the absence of the SC.
• External reports will be reviewed, documented in the SHCN Information System and initialed, dated, and filed.
• Personal contacts should include the individual’s first and last name, their relationship to the participant, or their title and organization.
• Do not copy and paste email correspondence (as a whole, screen shot, or quoted statement) into the SHCN Information System, a summary of the correspondence must be documented.   
• Entries in the SHCN Information System “Forms” screen do not require additional documentation in the Progress Notes.
• Use of abbreviations and acronyms are limited to the DHSS/SHCN approved abbreviations/acronyms list.

Reporting Complaints, Concerns, Unusual Events

The “Confidential Event Report” (CER) is completed by the person first aware of the event. If appropriate, the person aware of the event may take steps and/or make recommendations toward resolving the issue. The report is to be forwarded to the RC within the initial 24 hours after the concern has been identified for review. The RC will then route the CER to PM, Associate Bureau Chief, Bureau Chief, and designated program staff.

RCs will keep the original electronic copy of the CER form completed by the SC. The SCs shall not keep any copies (electronic or written) of the CER submissions. RCs will facilitate updates and follow up to the CER if additional information is received.

Documentation of Hotline Calls

Documentation of a hotline call requires two separate Progress Note entries as follows:

• The first progress note entry documents the entire incident (without mention of making a hotline call). The appropriate ‘Contact Type’ selection will indicate how the SC learned of the event. The second progress note entry documents the action of making the hotline call.  The ‘Contact Type’ selection is always ‘Other’. The body of the progress note will only state ‘A hotline call was made.’ No additional statement is to be entered. This note entry will follow the first progress note in date/time sequence.

Death Notification

When notified of the death of a participant, the SC shall complete and submit a Death Notification form to the RC within 24 hours of notification of the participant’s death. The RC will review the report and forward it to the PM and other designated staff (NOTE: A condolence letter is to be completed and routed to Central Office in same manner as is done for the Death Notification form).    

Monthly Information and Education Contact Reports

Activities such as public information, referrals, education, etc. are also a public health function. This is required to ensure that public contact of all types is included in reports to federal and other funders. This information helps to ensure the continuity of program provision. Therefore, SHCN staff are required to track and count the number of people, not enrolled in an SHCN program, which they provided with information, education or referred to another program. Multiple contacts with the same individual should count as one contact. When in doubt include the contact.

The number of these contacts is entered on a Monthly Information and Education Contact Report Form and is then submitted to the designated person. A report covering the previous month is due in Central Office on the fifteenth of the following month. For example the report covering contacts made in March would be due by April 15^th.