Service Notes & Documentation

Accurate documentation helps show what authorized services were provided and supports correct payment. The documentation you must complete depends on your provider type, the program through which the person receives services, and instructions from the person’s case manager, personal agent, service coordinator or local office.

• Personal Support Workers (PSWs) are required to submit progress notes with their timesheets or service-delivery records according to their program’s instructions. 

• Homecare Workers (HCWs) and Personal Care Attendants (PCAs) generally document their time through OR PTC DCI. Additional documentation requirements may depend on the authorized service and program instructions.

Always follow the person’s current service plan and the official instructions provided for your role. Do not perform or document services that have not been authorized.

PSW Progress Notes

PSWs must document the authorized services they provide. A progress note explains what happened during the service period and what the PSW did to support the person.

A useful progress note should include:

• The PSW’s name and the name of the person receiving services

• The date of service and the date the note was written

• The specific assistance or support provided

• How the support addressed the person’s needs, goals or desired outcomes

• Relevant progress, changes or new support needs

• Any difficulty completing an authorized task, including when the person declined support

Write clearly, respectfully and factually. Describe what actually occurred instead of using opinions, vague statements or identical “cookie-cutter” notes.

Submit progress notes according to the instructions provided by the person’s CDDP, Brokerage, CIIS program, personal agent or service coordinator. A missing required progress note may delay approval of the related timesheet or claim.

Protect Privacy and Use Professional Language

Service and progress notes become part of the person’s official record. They may be reviewed during monitoring, audits, investigations or legal proceedings.

When writing a note:

• Include only information relevant to the authorized services provided

• Use respectful, person-centered language

• State observable facts rather than assumptions or personal opinions

• Use the person’s preferred name and pronouns when instructed

• Write clearly and avoid slang or unexplained abbreviations

• Do not include the names or private information of other people receiving services

• Submit and store documentation using the secure method required by the program

Do not copy the same note repeatedly. Each note should accurately describe the services and circumstances for that specific person and service period.

Correcting Documentation

If you discover an error or missing information, do not hide it, erase it or create a misleading replacement.

• Contact the person or office responsible for reviewing the documentation

• Explain what needs to be corrected

• Follow the program’s instructions for submitting a corrected note, timesheet or service-delivery entry

• Keep the original dates and information accurate

• Do not change authorized hours or services without approval

• Keep a copy of the corrected documentation when permitted

For PSWs, contact the CDDP, Brokerage, CIIS program, personal agent or service coordinator that reviews the claim.

For HCWs and PCAs, time-entry corrections are generally made through the OR PTC DCI Web Portal. Contact the appropriate local office or program when the correction involves authorization, service information or something that cannot be corrected in the portal.

Correct mistakes as soon as possible. Missing or inconsistent documentation can delay review and payment.

Incidents and Abuse Require Separate Reporting

Writing something in a service or progress note does not replace required incident or abuse reporting.

If an injury, accident, serious illness, hospitalization, safety concern or other unusual incident occurs, promptly follow the reporting instructions provided by the person’s program. Contact the person’s case manager, personal agent, service coordinator, local office or other designated program contact.

Providers may also be mandatory reporters of suspected abuse or neglect. Do not wait for a timesheet or progress-note deadline to make a required report.

If someone is in immediate danger, call 911.

To report suspected abuse or neglect in Oregon, call 855-503-SAFE (7233) or use Oregon’s official abuse-reporting resources.

Where to Get Help

If you are unsure what documentation is required, ask before submitting your timesheet or claim.

• PSWs: Contact the person’s CDDP, Brokerage, CIIS program, personal agent or service coordinator.

• HCWs: Contact the local ODHS or Area Agency on Aging office responsible for the person’s services.

• PCAs: Contact the PCA Program, Comagine Health or the program contact identified in your enrollment and service materials.

• OR PTC DCI problems: Use the official PTC DCI help resources.

• eXPRS problems: Use the official eXPRS help resources or contact the office reviewing the claim.

When asking for help, describe the problem without sending Social Security numbers, banking information or unnecessary private information.

Is something on this page outdated or incorrect?

Please let us know so we can keep My Homecare Companion accurate and up to date for Oregon care providers.