Learning portal
For enrolled learners, faculty, and partner sites
Enter the password from your welcome email. Lessons, slide decks, handouts, and post-tests are inside.
This lock is a courtesy, not security. Before launch the host must protect this folder (see CLAUDE.md). Nothing confidential belongs here until then.
CHW 104: Service Skills, Case Management and Documentation
104.2 Documentation, Supervisor Review and Release of Info
Clear notes, timely review, release forms and keeping records safe
Your materials
Slides (PowerPoint) Handout (Word)
For instructors
Facilitator guide Printable pre and post tests Quiz (LMS import)
What you will learn
- Write objective notes that separate facts from opinions
- Use the DAP format to document a client contact
- Explain what a valid release of information must include
- Store and share client records using the minimum necessary rule
Start here
If someone read your notes about a client out loud to that client, would you feel proud of what they heard?
Lesson
Why we write it down
- Protects the client: Good notes keep care on track, so the next worker knows what was done and what comes next.
- Ohio requires it: Ohio rules say CHWs must document client data completely and accurately, and never falsify a record.
- Supports the team: Supervisors, nurses and providers use our notes to plan care and catch problems early.
- Shows our value: Notes become the data that prove what CHW work does for our community.
Objective and subjective
Objective (facts)
- Client said, "I have not eaten since yesterday."
- Refrigerator had milk and bread only
- Blood pressure reading was 150/95 on the program cuff
- Client arrived 30 minutes after the set time
Subjective (opinions)
- Client is lazy about eating
- House is a mess
- Client does not care about her health
- Client is always late on purpose
Writing a DAP note
DAP is a short, clear format for CHW notes:
- D: Data: What the client said and what you saw or measured. Facts and quotes.
- A: Assessment: Progress on goals and needs found. This is not a diagnosis.
- P: Plan: Next steps, referrals made, education given, and the next contact date.
- Sign and date: Add your name, the date, and the contact type: visit, phone or video.
Timely notes and supervisor review
- Write within 24 hours: Our program rule: finish each note within 24 hours of the contact.
- Flag urgent items now: Safety concerns or health changes go to your supervisor the same day.
- Submit for review: Send notes to your supervisor on the schedule your program sets.
- Use the feedback: Fix what the supervisor asks and ask questions when unsure.
- Correct the right way: Never erase or delete. Follow agency policy and mark the date and your initials.
What a release of information must include
| Part | What it says |
|---|---|
| What | The exact information to share |
| From whom and to whom | Who shares it and who receives it |
| Why | The purpose, or at the client's request |
| How long | An expiration date or event |
| Signature | Client's signature and date, or their legal representative |
| Rights | Can revoke in writing; services do not depend on signing |
Minimum necessary and safe storage
- Minimum necessary: Share only the information needed for the purpose, not the whole file.
- Lock it up: Paper in locked files. Electronic records behind passwords, on work devices only.
- No personal channels: No client details on personal phones, social media, or personal email.
- In the field: Never leave files in sight in a car. Log out of devices in public places.
Records, trust and history
- What we see: Mr. Hill in East Cleveland refuses to sign any form. He says paperwork has been used against his family before.
- Why it happens (upstream): Many families have seen records used to deny benefits, take children, or target neighborhoods. Distrust is a learned response.
- What we can build on (assets): Plain-language forms, a trusted pastor or neighbor present, clear choices, and CHWs from the community who explain every line.
Situation: the phone call asking for info
Situation: A woman calls and says she is Ms. Thompson's daughter. She wants to know what Ms. Thompson talked about at yesterday's visit in Glenville. There is no release on file for the daughter.
What do you say and do?
- Do not confirm that Ms. Thompson is a client
- Politely explain you cannot share without written permission
- Offer to pass a message or ask Ms. Thompson about a release
- Note the call and tell your supervisor
Talk it over
- What words do you use in daily talk that would be unfair in a client note?
- When might a client want family involved, and how would you set that up?
- Where could client information leak in your daily routine?
Study sheet
The big idea: Clear, honest, timely notes and careful sharing protect our clients and earn the community's trust.
Key points
- Write what you saw, heard or measured. Use the client's own words in quotes and leave out labels.
- DAP notes: Data, Assessment of progress (not a diagnosis), and Plan with the next contact date.
- Our program rule is to finish notes within 24 hours, and flag urgent items the same day.
- Never erase or delete a note. Correct it following agency policy, with date and initials.
- A release names what is shared, who shares, who receives, why, and when it expires.
- Clients can refuse or revoke a release, and services cannot depend on signing it.
- Share only the minimum necessary, and keep records locked and off personal devices.
Remember
- Ohio rule 4723-26-10: document completely and accurately; never falsify a record
- DAP = Data, Assessment, Plan
- Release parts: what, from whom, to whom, why, expiration, signature
- No release on file means no sharing, not even confirming someone is a client
Ask yourself
- Would I be comfortable if the client read this note?
- Am I sharing only what this person needs to know?
Vocabulary
| Word | What it means |
|---|---|
| Documentation | The written record of what happened with a client: contacts, needs, steps and plans. |
| Objective | Facts you saw, heard or measured, including the client's own words in quotes. |
| Subjective | Opinions, guesses or labels. Keep them out of client notes. |
| DAP note | A note format with three parts: Data, Assessment of progress, and Plan. |
| SOAP note | A medical note format: Subjective, Objective, Assessment and Plan. |
| Supervisor review | When a supervisor reads and checks a worker's notes to support quality and safety. |
| Release of information (ROI) | A signed form that gives permission to share specific information with a named person or agency. |
| Revoke | To take back permission. A client can revoke a release in writing. |
| Minimum necessary | Sharing only the information needed for the purpose, not more. |
| Protected health information (PHI) | Health information that can identify a person, protected by federal privacy law. |
| Falsify | To make a record untrue on purpose. Ohio rules forbid it. |
Real-life situations
The late note
Andre, a new CHW in Slavic Village, did four home visits Friday and plans to write all his notes Monday afternoon.
What to do
- Write short notes the same day, while memory is fresh
- Finish full notes within 24 hours, per program rule
- Tell the supervisor that day about any safety or health concern
- Ask the supervisor for help if the caseload makes timely notes hard
Why: Late notes miss details and can delay help. Ohio rules require complete and accurate documentation.
The label in the note
Your coworker's draft note says a client in Clark-Fulton is "noncompliant and difficult." The client missed two appointments because her bus pass ran out.
What to do
- Suggest rewriting with facts: missed two visits; client said her bus pass ran out
- Add the plan: help apply for transportation help
- Keep the talk private and respectful
- Bring questions on note style to supervision
Why: Labels follow clients and hide upstream causes. Facts lead to real solutions.
The partner wants the whole file
A food pantry partner asks you to email them a client's full intake packet so they can sign her up. The client signed a release for the pantry to get her name, address and household size only.
What to do
- Check the release to see exactly what it allows
- Send only her name, address and household size
- Use the secure method your agency approves
- Note what was sent, to whom and when
Why: A release covers only what it names. Sharing the minimum necessary protects the client.
Activity: Fix the note
About 25 minutes.
- Read the practice note from the facilitator. It is made up and full of labels and missing facts.
- Underline every opinion or label.
- Rewrite the note in DAP format, using facts and the client's own words.
- Add a plan with one referral and a next contact date.
- Swap with a partner and check: would the client feel respected reading it?
Post-test
Ten questions. You need 75% to pass, with one retake. Your result is saved in this browser.
Sources
- Ohio Administrative Code 4723-26-10, Standards of safe care by the CHW
- Ohio Administrative Code 4723-26-13, CHW training program curriculum
- 45 CFR 164.508, Uses and disclosures for which an authorization is required
- HHS, Must an authorization include an expiration date?
- HHS, Minimum Necessary Requirement
- StatPearls, SOAP Notes
- Noridian Medicare, Documentation Guidelines for Amended Medical Records