Form 2058, Case Activity Record

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Effective Date: 2/2011


Updated: 2/2011


This form may be used as an ongoing narrative to record information that is not required documentation on other forms. Examples include, but are not limited to:

  • initial contacts and scheduling;
  • phone calls/contacts with the consumer or responsible parties other than monitoring contacts;
  • negotiations and other contacts with providers;
  • justifying no change to the service plan after a reported change; or
  • the reason the consumer is not referred to Primary Home Care, although Medicaid eligible.

This form may not be used in place of Form 2314, Consumer Satisfaction Interview. Form 2314 is required for all monitoring contacts and reassessments.

Use of this form is optional.

Detailed Instructions

Consumer Name — Enter the name of the consumer.

Consumer ID No. — Enter the consumer's identification number.

Page — Enter the page number to keep the narrative in chronological order.

Action Date — Enter the date the case action occurred or contact was made/received.

Type of Contact — Record home visit, phone contact, office visit, etc.

Action/Narrative — Record any contacts with the consumer or responsible party acting on behalf of the consumer, or contacts with providers that are not recorded elsewhere in the case file. Record action taken or justification for not taking action, or other significant information not recorded elsewhere in the case file.

Case Manager Signature and Date — The case manager must sign and date each entry so it is clear who entered the information and the date the recording is done. The signature must be legible or the name of the case manager printed on the form.