Documentation in the Notes Feature
Table of Contents
Overview
The Notes feature is an important part of member documentation in Pear Suite. While structured data is collected through activities and forms, notes allow you to capture the full story of your work. Notes can be freeform or created using a reusable template. Both options help ensure that important details about a member’s situation are recorded and available for your team. Using notes consistently ensures that important details are captured and shared, allowing every team member involved in a member’s care to stay on the same page. Strong documentation creates a clear record of needs, progress, and next steps, which supports continuity of care across visits and staff. Notes also serve as required documentation for reimbursement, showing that services were delivered and goals were addressed.
Best Practices for Documentation
Good documentation ensures that members receive consistent support and that organizations can demonstrate the value of their work. When notes are written clearly and in a timely manner, they allow any staff member to step in and understand what has happened, what is happening now, and what should happen next. This continuity of care is especially important when multiple team members are involved in supporting the same member. Notes also provide the evidence required for reimbursement, confirming that services were delivered and goals were addressed. To meet these expectations, notes should be written promptly after each encounter, focus on facts and observations rather than opinions, and be detailed enough to give a full picture of the interaction. Templates can help keep documentation consistent, reduce the chance of missing key details, and save time across the team.
Ways to Create a Note
Notes in Pear Suite can be created in three main ways: during an activity, from a member’s profile, or at the end of an activity in the Update Activity window.
Adding a Note…
During an Activity
You can add notes while completing an activity. This allows you to document information in real time as you support a member. In the sidebar on the left, click the Notes tab.
In the Notes section, click + Add Note to create a new note. You can either select a note template or type a freeform note.
Once saved, the note will appear in the Notes list. By default, only notes tied to the activity you are currently working in will display here. To see all notes for the member, click the View All toggle at the top of the Notes section. This expands the list to display every note in the member’s record, not just the ones connected to the activity.
From the Member Profile
Notes can also be created from a member’s profile. In the Member Notes section on the right, click + Add Note to create a new note.
Choose a note template, if one is available, or enter a title and write a freeform note, then select Create Note.
The note is added to the member’s record and appears in the Member Notes section. Notes can be edited or redacted, but they cannot be deleted, and Pear Suite maintains a full edit history for transparency and compliance.
At the End of an Activity
When you complete an activity, the Update Activity window gives you another opportunity to add a note. This is helpful for summarizing the encounter, recording follow-up steps, or capturing additional context that was not entered during the activity itself. Notes added here are also saved to the member’s record and follow the same rules around editing and history.
Click Finish in the top right of the activity. The Update Activity window opens.
In the Notes area, select Add Note. Choose a note template if one is available, or enter a title and write a freeform note. Select Create Note. The note is saved to the member’s record and linked to the activity.
Notes and Billing
When a note is tied to a Billable Activity, it is automatically included with the claim submission for that activity. It's important to use clear, factual documentation and include required encounter details so the claim accurately reflects the services provided. The note becomes part of the member’s profile and the claim for compliance and audit purposes.
Documentation Requirements for CHW Services in Medi-Cal
To assist you in aligning with California's Department of Health Care Services' (DHCS) guidance, Pear Suite provides two note templates, an Initial Assessment template, and a Progress Note template to support your documentation requirements.
Initial Assessment Note Template
There are four fields in the Initial Assessment Note.
- Primary Needs/Goals: This is where you state the member’s primary needs and goals in their own words when possible. You will also want to add any baseline information that explains why support is needed today.
- How Do Goals Relate to Member's Health: Here you will explain the member’s goals and how it relates to their health. For example, how housing affects safety, or how transportation affects access to care.
- Next Steps: Here you will list what will happens next, who is responsible, and by when. This includes referrals, tasks, or a follow-up contact.
- Additional Information: This is an optional field where you can add context that supports the encounter, such as member strengths or barriers, preferences, coordination notes, or other information relevant to the member’s care.
Example of an Initial Assessment Note
Primary Needs/Goals: CHW and member completed a social determinants of health assessment for 15 minutes, which identified Food Access and management of a Chronic Health Condition (diabetes) as priorities. Member stated that food insecurity has led to skipped meals and inconsistent blood sugar checks. CHW and member spent 30 minutes discussing current eating patterns, challenges with accessing affordable healthy food, and how these challenges affect diabetes control. CHW then spent 30 minutes providing health education about the relationship between balanced meals and blood sugar stability, and 15 minutes helping the member identify local resources, including CalFresh and food pantry options.
How Do Goals Relate to Member's Health: Member shared that limited access to food has caused fluctuations in blood sugar, fatigue, and difficulty focusing at work. Addressing Food Access is expected to support diabetes self-management, reduce the risk of complications, and improve energy and daily functioning.
Next Steps: CHW referred the member to CalFresh and provided a checklist of documents needed for the application. Member agreed to gather documents and complete the application before the next follow-up. Member also agreed to track meals and blood sugar readings for review at the next visit. Follow-up scheduled in two weeks for 9/25/25.
Additional Information (Optional): Member mentioned they prefer evening appointments because mornings are harder due to fatigue. CHW noted that the member has strong family support, as their daughter regularly checks in and encourages them to stay on top of diabetes care.
Progress Note Template
There are four fields in the Progress Note template:
- Summary of Encounter: This is where you summarize what happened during the visit or call, and list the minutes for each topic you covered so the total time matches what you billed that day.
- Progress On Goals, Relation to Member Health: Here you explain how today’s work moved the member toward reaching their goals, and how your support relates to improving their health.
- Next Steps: Here you list what will happen next, who is responsible, and by when. This includes referrals, tasks, as well as any ongoing follow-ups.
- Additional Information (Optional): This is an optional field where you can add context that supports the encounter, such as member strengths or barriers, preferences, coordination notes, or other information relevant to the member’s care.
Example of a Progress Note
Summary of Encounter (Include minutes spent on each topic): CHW met with the member for a scheduled follow-up visit lasting 60 minutes. CHW spent 30 minutes reviewing progress on CallFresh documents and identifying what remains before submission. CHW spent 15 minutes reviewing the member's food and blood sugar log since the last visit, noting patterns when meals were skipped. CHW spent 15 minutes problem-solving current food access barriers, including identifying a nearby pantry, planning two low-cost dinners, and comparing store prices.
Progress On Goal(s), Relation to Member Health (How did assistance impact member's health): Member reports since accessing the food pantry near them, there has been an improvement in consistency of meals, supported by family encouragement. Blood sugar readings were more stable on days when meals were balanced. Member expressed confidence in completing the CalFresh application and is motivate to continue tracking food and glucose. Addressing Food Access need is beginning to positively affect diabetes management, energy, and overall daily function.
Next Steps: CHW will follow up with member in two weeks to confirm CalFresh application submission and review next steps. Member agreed to continue using the food and glucose log and bring updated records to their next visit. CHW provided low-cost meal planning resources to further assist member in addressing their health needs.
Additional Information (Optional): Member mentioned they are interested in attending a diabetes support group offered at the local community center but would prefer an evening session. CHW will check availability and share details at the next follow-up.