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Action Notes Checklist
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Full Date of Contact
Name and Title of Person(s) Contacted/Present

Place of Contact (HV, PV, Etc.)

  • Residence
    • Home Visit (HV)
    • Program Visit (PV)
  • Vocational
  • Etc.

Type of Contact (TC, EM, FTF)

  • Face-to-Face (FTF)
  • Telephone Call (TC)
  • E-mail (EM)
  • Collateral
  • Etc.
Follow Up

Summary of Contact:

  • Link to the Person's Plan
  • Observations about Quality of Life
    • Issues
    • Events surrounding quality of life areas
    • Changes in medical and/or dental conditions
    • Etc.
  • Medical/Dental Updates and Changes
  • Actions - what has happened
    • What has taken place
    • What did take place during contact
    • What needs to happen and
    • Who will do it (follow-up)
  • Client Status
  • Medicaid Billing Documentation

Signature/Electronic Signature and Date

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