Why Documentation Matters

Documentation protects the client, the RF, & BIA-NE. 

It helps us:

• remember what has already happened

• track progress over time

• coordinate with other providers

• make sure nothing falls through the cracks

• meet grant and reporting requirements

• show the impact of our work

Salesforce is our "true north." If it is not in Salesforce, the rest of the team cannot see it, track it, or build on it.

Best Practice: Enter information as soon as you have it.

The longer you wait, the more likely it is that details will be forgotten, duplicated, or entered incorrectly.

RF Levels : Information & Referral vs. Case Management

BIA-NE tracks two general levels of service.

1. Information & Referral (I&R) - Brief help, education, or referral totaling less than 120 minutes of staff time

2. Case Management - Ongoing support totaling more than 120 minutes of staff time

The best part? Thanks to Salesforce, you do not need to manually change anything in Salesforce for a case to move from I&R to Case Management/Resource Facilitation. The system tracks this automatically for reporting purposes. 

The important thing is to document your time and contacts accurately.

Initial Client Intake Process

Best Practice: Enter information into Salesforce as soon as you have it! (Yes, we're repeating it from above here because we can't say this piece enough!)

Everyone who contacts BIA-NE should be entered into Salesforce as soon as possible, no matter how they come to us. Many people contact BIA-NE more than once over time. 

When A Referral Comes Through The Main (Phone) Line Or The Website Form/s

The RF Team Lead will first check Salesforce to make sure the person is not already in the system.

If the person is not already in Salesforce, the RF Team Lead will:

• create a new contact using whatever information is available

• determine which RF should receive the referral based on where the person lives

• add a task note to the contact record describing the referral

• create a task for the assigned RF that says:  "Contact to schedule intake"

• assign that task to the appropriate RF

• transfer ownership of the contact to that RF

• make sure the RF receives an email notification about the new referral

The task should not include a date or time for the intake. The assigned RF will decide that after reviewing the referral and contacting the client.

If the referral does not include enough information to know where the person lives, the RF Team Lead will contact the person to determine which RF should receive the referral.

If the person lives outside the RF Team Lead’s region, the RF Team Lead will transfer the contact to the appropriate RF and make sure the “send email” box is checked so the receiving RF knows there is a new referral waiting.

If the person is already in Salesforce, the RF Team Lead will:

• add a task to the contact record that says:  "Contact individual and open a new case"

• transfer the contact to the appropriate RF if needed

• make sure the assigned RF receives an email notification

If the assigned RF already owns the contact, the RF Team Lead will simply send the RF an email letting them know the client needs to be contacted and a new case may need to be opened.

When A Referral Comes Directly To An RF

If you receive a referral directly, search Salesforce first to make sure we have not already worked with the person.

If the person is not already in Salesforce:

• create a new contact record within 24 hours

• enter at least the person’s name right away

• add any other information you received from the referral to the contact record

All information gathered before intake should be entered on the contact record, not in a case.

After saving the contact, create an initial task note such as: "Referral received. Initial information entered on contact page."

Within 48 hours, create a follow-up task to contact the client and schedule an intake call or visit.

Do not open a case until the intake has been completed.

Until then, continue documenting outreach and communication as task notes on the contact record.

Completing The Intake

Once you reach the client, explain that BIA-NE completes an intake to learn more about the person, their brain injury, and what support may be helpful.

Explain that:

• information is entered into Salesforce so BIA-NE can track what has already been discussed and avoid making the client repeat themselves later

• the intake usually takes 30 minutes or more

• it is helpful to schedule the intake for a time when the client has enough time and energy to complete it

During the intake, take notes about:

• the client’s history and current concerns

• possible areas of need

• goals the client wants to work on

• information that should later be added to the case record

On the right side of the Salesforce contact page is a list of required information fields. Complete as many of these as possible during intake.

These fields are important because BIA-NE uses them for reporting, grant requirements, and showing the impact of our work to leadership and funders.

After the intake is complete and the required information has been entered, open a new RF case.

Identifying Needs

The client’s needs drive the Resource Facilitation process.

The most important question is:

What does the client want to work on right now?

RFs may notice additional needs during the conversation, but if the client is not ready to work on those areas, they should not be marked as active.

Instead:

• add them as “identified but not active”

• revisit them later if the client decides they want help with them

For example, a client may say their top priority is seeing a doctor, but they do not have health insurance. In that situation, the RF may need to explain that obtaining insurance is the first step, even though the larger goal is medical care.

Keep active needs focused and manageable.

When Giving An Outbound Referral

The client's identified needs are what drive Resource Facilitation.

In Salesforce:

• keep no more than five needs marked as "active" at one time

• mark other concerns as "identified but not active"

• update needs as priorities change

• close needs when they are completed or no longer relevant

Needs should reflect what the client wants to work on, not just what the RF thinks is important.

Case Notes : What Good Documentation Looks Like

Case notes should be:

• clear

• brief

• factual

• specific

• timely

Document what happened, not your opinion about what happened.

• Instead of: "Client was difficult and unmotivated."

• Use: "Client stated they were overwhelmed and did not complete the application. Client agreed to try again next week with RF support."

Clients have the right to request their records. Notes may also be reviewed for audits, supervision, or legal purposes. 

Write every note as though someone else may need to understand the case later.

A good case note usually answers:

• what happened

• who was involved

• what the client said or did

• what you said or did

• what the next step is

Tasks & Follow-Up

Every task should lead to another task.

Best Practice: After documenting a contact, always create the next follow-up task unless you are closing the case. 

Examples:

• call client next Tuesday

• research housing options

• send Release of Information form

• follow up after doctor appointment

• check whether referral was completed

As a general rule:

• follow up within 3 business days after intake

• continue follow-up at least every 1-2 weeks while the case is active

• follow up sooner if the client has urgent or complex needs

Let clients know they can contact you before the next scheduled follow-up if something changes.

Referrals & Coordination

Whenever you give a referral, document it.

Include:

• where the client was referred

• what information you provided

• whether the client plans to contact the resource themselves

• whether you assisted with the referral

• whether a Release of Information was used

If the referral source is not already in Salesforce, create an organization record and connect it to the client's case.

If the client is unable to make the referral independently because of memory, communication, physical, or other barriers, you may assist with the referral after obtaining permission.

Emails, Documents, & Uploads

All client-related emails should be linked to the correct case or contact record.

Upload important documents as soon as possible, including:

• signed Releases of Information

• screening results

• referral forms

• tip sheets

• supporting documents needed for services

Use consistent naming conventions so documents are easy to find later (e.g. - ROI_Smith_Jane_2026-04-03).

Closing A Case

Before closing a case:

• make sure all notes and tasks are complete

• document the outcome

• record why the case is closing

• confirm there are no unfinished follow-up items

Common reasons for closing a case include:

• goals completed

• client declined further services

• unable to reach client after repeated attempts

• referred to another service

• client moved or is no longer eligible

Before closing due to no response, make at least:

• 3 contact attempts for most clients

• 5 contact attempts for domestic violence clients

Whenever possible, send a final message letting the client know:

• you have been unable to reach them

• the case will be closed on a certain date

• they are welcome to contact BIA-NE again in the future

Documentation Quick Reference (Best Practice!)

TASK WHERE IT GOES WHEN TO COMPLETE

New referral received Contact record Within 24 hours

Contact client to schedule intake Task on contact record Within 48 hours

Intake completed Contact record & new RF case Same day

New need identified Case need section Same day

Referral provided Case note & referral section Same day

Signed ROI received Upload to case As soon as signed

Follow-up after intake Task Within 3 business days

Case closure note Case note Within 3 business days of closing

Training & Help