Recordkeeping in the WIPA Program

There are several aspects of recordkeeping in the WIPA program that are important for CWICs to recognize. Recordkeeping does not simply refer to the case file that you document for each beneficiary served, it also entails knowing the proper procedures and documentation requirements when working with representative payees and other interested stakeholders. WIPA case records are to be kept separate from all other agency records with access limited to CWICs only. File cabinets must be kept locked at all times with access to the key limited to certified WIPA staff members who have completed the federal security clearance required by SSA.

Beneficiary Records

All beneficiaries served by the WIPA project who meet the project eligibility criteria should have a written record or file. Beneficiaries who only receive information and referral services would have very little in the file, while individuals receiving intensive or ongoing services would have a longer case record. The basic components of a WIPA case record are listed below.

1.Information Gathering Form or Intake Form with all SSA required contact information and demographic data. A sample Information Gathering Form has been provided at the end of this unit in the section entitled “Conducting Independent Research”, but this form is not required to be used by WIPA projects as long as all of the required data elements are collected.

2.Case notes that describe services rendered, issues discussed and actions taken. Notes should be made after every contact and should appear in chronological order. Notes must be dated with service time indicated and signed with staff title listed. Black or blue ink should be used for all case notes with no information covered with marker or white out. Mistakes should be struck through with a single line.

3.Copies of any release of information forms used to access benefits information from SSA or other Federal, state or local agencies. Only the form SSA-3288 may be used to access information about a beneficiary from the Social Security Administration. Other release of information forms used by the agency must specifically indicate what information is being sought, must be signed by the beneficiary and have an expiration date.

4.Copies of Benefits Planning Queries (BPQYs), statements of benefits, or other correspondence that verifies public benefits received, current benefits status, payment amounts and work incentives used. This is required for beneficiaries receiving intensive services. A release of information should be on file for each item to verify that permission was provided to obtain it.

5.Verification that the beneficiary has read and understands the WIPA project policies and procedures. This would consist of a signature sheet signed by the beneficiary, or the legal guardian and the CWIC. At a minimum, these policies should cover:

  • Services to be provided and any limits to these services
  • Beneficiary responsibilities with regard to WIPA services
  • WIPA service eligibility criteria
  • Confidentiality policy
  • Grievance/complaint procedure or appeals process including information on the PABSS program
  • Any other beneficiary rights the agency wants to review
  • Any disclaimers about work incentives advisement

6.Copies of any written Benefits Summaries & Analysis reports, Work Incentive Plans, and summaries of other advisement provided or related correspondence. This should include SSI calculation sheets and title II disability benefit charts or timelines as appropriate.

7.Copies of any correspondence to or from other agencies regarding the beneficiary such as letters to Social Security or the state Medicaid department.

8.Copies of any work incentives information such as PASS documentation, documentation on IRWEs, BWEs, etc. This may also include copies of pay stubs or any other correspondence or information related to the use of specific work incentives.

WIPA case records would NOT contain diagnostic, medical or disability information unless there was a compelling need for such information related to the WIPA services rendered. For example, it may be necessary to have disability information related to use of particular work incentives or potential barriers to employment.

Since WIPA case records may only be accessed by authorized CWICs, they should generally NOT contain forms or information related to other services the beneficiary has or is receiving from the same provider agency under a different program. A separate record should contain this information. A WIPA Beneficiary Record Review form can be found in the Conduction Independent Research section of this unit. This form may be helpful in setting up files. The most important factor is that files should be consistent throughout the WIPA project. It is inefficient for each CWIC to have different formats for compiling client files.

A Few Words about Case Notes

Quite simply, case notes are a narrative description of activity conducted for, with, about or on behalf of a beneficiary receiving services from a WIPA project. Case notes are a required component of WIPA project record keeping and represent one of the most important elements in maintaining a beneficiary’s case file. The purpose of case notes includes:

  • Providing a chronological description of services rendered to help CWICs stay organized;
  • Documenting services rendered and progress made to funding and regulatory agencies;
  • Allowing all multiple professionals working with the beneficiary to stay informed and up-to-date;
  • Providing a historical record for use when staff changes are made to insure continuity of services;
  • Providing a valuable method for WIPA project managers to assess service appropriateness and quality; and
  • Serving as an essential legal document when a case record is subpoenaed by a court of law.

Case Note Dos / Case Note Don’ts
  • Describe services rendered and result achieved
  • Record progress or lack thereof
  • Be clear, concise & accurate
  • Use direct quotes when appropriate
  • Write notes for each and every contact
  • D.A.T.E -Do At Time of Event!
  • Sign & date every entry
  • For mistakes, cross out with single line & initial
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  • No rambling
  • No value judgments
  • No assumptions or guesses
  • No judgments beyond your expertise
  • No blank spaces
  • No white-out or scribbles
  • No waiting to make notes
  • No one else may write your notes for you!

Other important things to remember about case notes:

  • Case notes may be hand written or typed, but the signatures must be original.
  • All information related to the persons served must be treated as strictly confidential per SSA’s guidelines!
  • Beneficiaries have the right to access their case files at any time to review the case notes and any other file contents.

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