Daily service documentation that reflects the Individualized Service Plan (ISP) is essential to show that Medicaid-funded services have been provided.

When you write service notes, it is important to:

• Know the person's service plan.
• Understand why service documentation is necessary and the importance of writing clear, detailed notes.
• Write down what you see, hear, or otherwise observe, rather than your opinions about what you see, hear, or observe. If you need to include your opinion, state clearly that it is your opinion.

What to Include 

• Who Include the full name of the person served and any other people they interact with during service delivery.
• What Include the name of the service that was delivered and details about the person’s responses, reactions, and level and types of engagement. 
  • How did you know they enjoyed or disliked an activity?
  • What did you observe?
  • What did they say or do?
• Where Be specific about where in the person’s home or in the community the service was delivered. If the person went from one location to another, include the method of transportation.
• When Include the date the service was delivered and the service start and end times.
• Why Why was the service delivered? The note must identify a clear link to outcomes and strategies in the service plan.

The service note should capture any new, relevant information about the person related to activities, skill-building, risks, and routine supports. If more than one direct care worker provides services on the same day, each worker must write their own service note.

What to Avoid in a Service Note

• Notes copied from previous service dates
• Notes not signed and dated by the worker who delivered the service with the date the service was delivered
• Notes that do not document the individual's unique opinions about or observed responses to supports