Case recording and documentation

Case Recording and Documentation for the Case Manager

The importance of good documentation can not be overemphasized. A Case Managers documentation assists in clinical management, justifies interventions and expenses, and defends from negligence. 

When documenting, Case Managers should maintain professional objectivity and document facts including quotations when appropriate. Opinions and biases should not be part of the medical record. The best time to document is during or right after the encounter.

What Should Case Managers Document

What should be documented will depend on the setting the Case Manager is working in. Examples may include, but are not limited to records of:

  • assessments
  • observations
  • monitoring
  • evaluation finding
  • interventions
  • progress with current treatment
  • modifications to the case management plan, including rational
  • outcomes
  • discharge planning
  • medical stability of patient with in 24 hours of hospital discharge
  • plan of care, including patient/family agreement of
  • patient/family education
  • evidence of continuation of care after discharge from inpatient setting
  • informed consent
  • precertifications for procedures
  • advance directives

In addition, all communication with the following must be documented

  • patient
  • family
  • insurer/payer
  • vendors
  • other health care providers both inside and outside the organization