✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on July 24, 2025.

Documentation

The importance of good documentation cannot be overemphasized. A case manager’s documentation assists in clinical management, justifies interventions and expenses, and defends against negligence claims. The information a case manager documents depends on the care setting. Case managers should maintain professional objectivity and record only facts (not biases or opinions) in documentation. Quotations may be recorded when appropriate. 

Case managers must document communication with all healthcare participants. The best time to document is during or immediately after an encounter. All documentation must adhere to client privacy and confidentiality requirements and be completed per regulatory and accreditation standards within the case manager’s practice setting. For accuracy and consistency, case managers should use standard tools for documentation.

CCMC’s Code of Conduct requires CCMs to document notification of discontinuation of case management services. Documentation must be provided to the client and all directly involved healthcare professionals and support service providers before discontinuing services. Case closure documentation should include the reason for closure and a closure summary.

Case summaries

Case summaries provide a concise overview of a client’s progress, interventions, and outcomes. They are particularly important during transitions of care.

Purchasers of case management services, such as insurers, employers, or third-party administrators, may require case managers to deliver case summaries on a monthly, quarterly, or otherwise agreed schedule. The reports justify the cost-benefit of case management, demonstrate the value and effectiveness of services, and provide insight into clients’ progress.

Workers’ compensation case summaries

In workers’ compensation (WC) case management, case summaries are often required to document an injured worker’s progress, return-to-work status, and ongoing care needs. WC case summaries are typically submitted to insurance carriers, employers, or legal representatives and serve as a key communication tool in managing the claim.

This article shares a portion of the information covered on this topic in CCM Certification Made Easy, 4th Edition by Deanna Cooper Gillingham, RN, CCM, FCM (2025). For more details on this topic and related concepts, purchase your copy at CCMCertificationMadeEasy.com