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820 Chapter 4:Working with families • Section 8: Narration and computer entry (07/2026) • Narratives should contain concise, descriptive, objective observations of an individual’s engagement. • All personal development plans, support services, timelines, accommodations, referrals and family engagement should be recorded in narration. The following case information and actions should always be included in narration: • Results of screenings and assessments • Specific accommodations, and whether or not they were offered and accepted • Case plans and support services • Re-engagement efforts • Participant goals • Referrals to resources and community partners • Receipt of documents or information from families, related to case management • All completed and attempted contact with participants and individuals. The following information is considered inappropriate for the case record and should never be narrated: • Child abuse reports • HIV/AIDS status • Personal opinions • Information not relevant to the case or working with the family. Note: When elderly abuse is reported to Adult Protective Services (APS), workers should only narrate the referral. Do not include any details of the alleged abuse. Use the following wording; “Based on information received, an APS referral was made.” Oregon Administrative Rule(s) 461-105-0010 — Rights of Clients Secure and restricted narration Health Insurance Portability and Accountability Act (HIPAA) requires ODHS|OHA to add a second level of security relating to substance use disorders or mental health. We are required to secure or restrict information when narrating or creating a disability record where a provider has included a diagnosis, prognosis or treatment information relating to substance use disorders or mental health. Secure narrations should be used in all situations where the narration or disability record includes a diagnosis, prognosis or treatment information from a qualified provider. Restricted narrations should be used only when the participant requests certain employees have access to a qualified provider’s diagnosis, prognosis and treatment information. Documenting plans