milwaukee county（密尔沃基县）.docVIP

Milwaukee County Behavioral Health Division WRAPAROUND MILWAUKEE Policy Procedure Date Issued: 9/1/02 Date Revised: 11/13/06 Section: ADMINISTRATION Policy No: 037 Pages: 1 of 2 (4 Attachments) Effective Date: 1/1/07 Subject: PROGRESS NOTES I. POLICY It is the policy of Wraparound Milwaukee that all client-related activities provided by Care Coordinators be documented in Synthesis (Wraparound Milwaukee’s IT system). II. PROCEDURE All Progress Notes (see Attachment 1 – Sample Progress Note Entry and Attachment 2 – Crisis Case Management Definitions and Documentation Guidelines) must be completed and finalized in Synthesis as soon as possible after the contact occurred. In all instances Progress Notes must be finalized within seven (7) working days of the contact. Every client file must have a Progress Note section that includes a printout of all completed, finalized and signed Notes. Progress Notes must be filed in each client’s chart by the 10th day of the following month (i.e., June Notes must be filed by July 10th ). Charts must NOT contain any Progress Notes in draft form. Progress Notes must be signed with the full name (or a minimum first initial and last name) of the writer and his/her credential (i.e., M.A., B.A., etc.) when the electronic signature feature is not used. If the electronic signature feature was not used and if the author of a Progress Note is not available to sign the Note (i.e., a Care Coordinator unexpectedly leaves an Agency), and that person cannot be located to acquire the signature, then it is permissible for the Care Coordination Supervisor or Lead to sign off on the Progress Note as follows: Kathy Miller, MSW for John Jackson, BS. A Progress Note should be entered into the Client’s Chart by the Supervisor or Lead, indicating why the Progress Note was signed by someone other than the author. At minimum, a weekly Progress Note documenting your face-to-face contacts (or attempts to make a face