North Carolina group home progress note requirements
Every page prints this at the foot, so a licensing specialist can look it up:NC DHHS DMH/DD/SUS Record Management and Documentation Manual (APSM 45-2), Chapter 6 'Documentation and Service Notes'; underlying rule 10A NCAC 27G .0206.
What the rule says
NC DHHS DMH/DD/SUS Record Management and Documentation Manual (APSM 45-2), Chapter 6 'Documentation and Service Notes'; underlying rule 10A NCAC 27G .0206 — Record Management and Documentation Manual for Providers of Publicly Funded Mental Health, Intellectual or Developmental Disabilities, Traumatic Brain Injury, and Substance Use Services; 10A NCAC 27G .0206 'Client Records'
“For twenty-four-hour facilities requiring shift notes, there must be a note for each shift, and the coverage hours for each shift must be clearly identified in each note”
What it asks a note to show
- Name of the individual receiving the service
- Service record number issued by the payor along with the Medicaid Identification Number (as applicable), or unique identifier issued by the entity
- Full date the service was provided (month/day/year)
- Name of the service provided
- Type of contact (in person, telehealth, telephonic, collateral)
- Place of service
- Purpose of the contact, tied to the specific goals in the plan
- Description of the interventions, treatment, and support provided
- Duration: total amount of time spent performing the service, matching what is submitted for billing (not required for event/per-diem billed services)
- Effectiveness of the intervention(s), treatment, or support provided, and the individual's response/progress toward goal(s)
- Service note authentication by the person who provided the service, with credentials and the date of authentication
- Any additional elements required by the Medicaid clinical coverage policy or State-funded service definition
Checked against the source document on 14 October 2026. This is a summary to help you find the rule, not legal advice; your licensing specialist reads the rule itself.
New to writing these? How to write a DSP shift note covers what the rules we have read ask of every note.
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Daily Progress Note
Alex was observed asleep and resting comfortably at the start of the shift. Staff supported Alex in completing his morning routine with verbal prompts. Alex chose to walk to the corner shop, where he paid for his own item. There were no problems or concerns during shift.
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