Contact Note Best Practices
Write documentation that meets audit requirements and tells the client's story.
Contact notes are the backbone of case management documentation. They prove services were provided, justify billing, and paint a picture of the participant's progress over time. Here's how to write notes that pass audits and actually help your participants.
What Every Contact Note Needs
At minimum, every contact note should include:
- Date and time: When the contact occurred
- Duration: How long the contact lasted
- Contact type: Face-to-face, phone, email, video
- Who was involved: Participant, family member, provider, etc.
- Purpose: Why you made the contact
- Content: What was discussed or observed
- Outcome/follow-up: What happens next
The SOAP Format
Many organizations use SOAP notes for consistency:
- S (Subjective): What the participant or others reported
- O (Objective): What you observed directly
- A (Assessment): Your professional analysis
- P (Plan): Next steps and follow-up needed
Common Mistakes to Avoid
- Vague language: "Checked on client" doesn't tell auditors anything. Be specific about what you checked and what you found.
- Copy-paste syndrome: Notes that look identical month after month raise red flags. Even stable participants have some variation.
- Missing the "why": Always connect your contact to the service plan. Why did this contact matter?
- Late documentation: Notes written days or weeks later lose credibility. Document within 24-48 hours.
- Opinion without observation: "Client seemed depressed" needs supporting observations like "reported not sleeping, appeared tearful."
Strong Note Example
Date: 12/10/2024 | Time: 2:15 PM | Duration: 45 min | Type: Face-to-face home visit
Present: Maria S. (participant), Rosa S. (daughter/caregiver)
Purpose: Monthly monitoring visit per service plan
S: Maria reports feeling "pretty good" and says she's been using her walker consistently. Rosa states attendant care services are going well and Maria is eating better since they adjusted her medication last month.
O: Home clean and organized. Maria ambulating with walker, appeared steady. Observed meal prep supplies in kitchen. Reviewed medication list—matches pharmacy printout. Maria demonstrated ability to use emergency alert pendant.
A: Maria stable and safe in home setting. Current services meeting her needs. Goal of maintaining independence in community being achieved.
P: Continue current service plan. Next monitoring visit scheduled for January. Will follow up with PCP office regarding upcoming annual wellness visit.
Weak Note Example
Date: 12/10/2024
Note: Visited client at home. Everything looks good. Services going fine. Will check back next month.
Problems: No time, no duration, no specifics about what was observed, no connection to service plan goals, no documentation of who was present.
Tips for Efficiency
- Use templates with required fields built in
- Document on a mobile device during or right after the visit
- Create phrase banks for common observations
- Set aside time daily for documentation catch-up
- Review notes before signing—typos hurt credibility
Write Better Notes Faster
One Care Portal includes contact note templates with required fields, phrase libraries, and mobile documentation. Spend less time writing and more time with participants.
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