WHAT WOULD YOU DOCUMENT?
Client says, “I don’t understand my lease.”
Client says, “I don’t understand my lease.”
Why the service was needed
Medical necessity
Missing section most likely to get a note denied
Medical necessity or intervention
Client is present for a home visit focused on skill-building and housing stability.
Case Management / Community Support Note
You check in with a client and document, “Client is doing well.”
Not billable; No medical necessity
Client’s unit is cluttered and attracting pests.
Coaching on unit maintenance and safety
If this isn’t clear, the note may be denied even if the work was done.
Why the service was needed
“Will follow up” is missing what?
Specific plan
Client is not present. Case manager coordinates with landlord or provider regarding housing concerns.
Client Not Present; Care Coordination Note
You visit a client at home to coach on cleaning skills to prevent eviction.
Billable
Client misses multiple appointments and avoids contact.
Engagement barriers and outreach efforts
Housing work becomes billable when it addresses this.
Functional impairment / housing stability
“Client was okay” should be replaced with what?
Observable response
Client becomes verbally escalated in public and requires de-escalation and safety assessment.
Crisis / Emergency Intervention Note
You call a landlord to clarify lease concerns; client not present.
Billable
Client becomes verbally aggressive at a benefits office.
Client becomes verbally aggressive at a benefits office.
If a note doesn’t connect to this, services may be questioned.
Treatment plan goal
Auditors want to understand why. Why what?
Why the service was necessary
Staff selects a Client Present note, but the client was not present for the service.
Incorrect note type. Should be Client Not Present / Care Coordination
You document a visit but don’t include client response.
Risky / may be denied
Client is housed but at risk of eviction due to symptoms.
Housing stability support tied to symptoms and functioning
Finish this sentence: “This service was necessary because…”
The client’s symptoms or functioning required it
Strong notes are longer: true or false
False — they’re clearer
Client is present, housing stability is assessed, coaching is provided, and next steps are documented.
Client Present; Case Management / Community Support Note
A note includes housing instability, intervention, response, and plan.
Strong, defensible, billable note