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Tip: Keep case management notes short and sweet

Case Management Weekly, April 7, 2010

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Case managers should document the medical record each and every time a case management intervention occurs or a patient’s status changes.

Case managers should reassess patients every day so they can adjust the case management plan according to patients’ current and projected outcomes of care.

The elements of a quality case management note include the following information:

• Day x of an expected LOS of y days (for example, “It is day two of a five-day expected LOS.”)
• Outcomes of care
• Changes to the plan based on the patient’s clinical outcomes
• Coordination of care activities
• Anticipated discharge plan
• Any updates to the patient’s social, financial or family situation
• The status of any referrals
• Any legal matters, such as guardianship or immigration status
• Any patient education needs

A long rambling note may be satisfying to the writer, but it may not satisfy the reader. Notes should be clear and to the point. Omit any editorial comments, as tempting as they may be. Don’t red-flag specific matters you may address, such as delays in completion of tests, treatments, or procedures, or delays in response by the physician or other team members. They don’t belong in the permanent record.

This week’s tip is adapted from Core Skills for Hospital Case Managers published by HCPro, Inc. For more information on this book or to order your copy, visit the HCMarketplace.

Do you have a question about a case management topic? Send it to editor Ben Amirault at bamirault@hcpro.com. An answer to your question might appear in a future issue of Case Management Weekly.

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