Documentation Requirements 650-25-45-35

(Revised 07/01/22 ML #3690)

Documentation should provide a clear summary of the current caregiving situation. All contacts relating to a caregiver must be documented in the Caregiver Assessment Tool.

Documentation must include, as applicable:

Date the referral was received.
Date of contact.
Purpose of the contact (initial, quarterly, annual, collateral, call received, call returned, etc.;).
Brief descriptive statement of the interaction with the caregiver/care recipient.
Identified service needs based on caregiver’s stated needs/goals;
Alternatives explored.
Service delivery options offered.
Rationale for the number of service hours/funds allocated.
Services accepted or refused by the caregiver.
Coordination with other services.
Caregiver’s choice of provider(s).
Description of materials provided such as the Caregiver Handbook, Voluntary Contribution Statement, Notice of Privacy Practices, or other materials.
Condition of or changes in the caregiver or care recipient situation.
Outcome(s) of any referrals provided to or made on behalf of the caregiver/care recipient.
Impact of the FCSP involvement on the caregiver/care recipient.
Caregiver/care recipient satisfaction with services.
Observations and/or concerns regarding caregiver home conditions.
Participation and completion of Powerful Tools for Caregivers and/or the department-approved dementia care services training as verification for enhanced respite.
Reports of any caregiver/care recipient concerns from other parties involved with the caregiver.
Any information relevant to the caregiving situation.