Page 2

AMENDING CASE NOTES/SECURITY: Certain individuals engaged in administering public assistance programs have system security that allows them to record their specific actions within the case note section of the eligibility system. These individuals are: 1. Eligibility staff members. 2. Pathway Advocates. 3. Specific regional and Central Office staff. 4. System programmers; and, 5. Claims and Recovery Unit staff. Case notes are a legal record of case history. A case note should only be changed or updated by the original author the same day it is entered. If it is later determined an error was made in a case note, an amended case note needs to be entered to document the change or correction. MEDICAL CONCERNS: Case notes regarding medical conditions require extra caution due to both HIPAA guidelines and Medicaid regulations. Only the 'minimum necessary' information should be included, and this would rarely include an actual diagnosis. The documentation in case notes should be more generic, e.g., 'serious medical condition present, see case file' or 'medical condition present that restricts activities, see case file' or 'mental health issues present, see case file'. Those references will alert subsequent eligibility staff member to investigate when planning later participation activities and also assist Central Office in extended benefit application considerations. It is important to be especially cautious in case notes with medical information that has the potential for discriminatory action by others if disclosed. Medical conditions should not be listed unless required for eligibility purposes and even then, general terms should be used such as blind. GUIDELINES: The following is a partial list of some circumstances requiring a system case note. The list for each phase of the eligibility determination and case management is to be used as a guide and not as an all-inclusive list. APPLICATION/REDETERMINATION INTAKE: 1. List programs involved and household composition. 2. Details of interview: a. Who completed the interview? b. Unusual/questionable circumstances. c. What community resources were discussed/shared. d. What referrals were made; and, e. What forms/resources were provided. ELIGIBILITY REQUIREMENTS: 1. Non-financial: a. Explanation to support disqualifications/ineligibility such as alien status, unusual SNAP situation etc.