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Documentation in an era of intense oversight

Case Management Weekly, June 13, 2007

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Documentation is the cornerstone of a case management department's practice and is becoming even more important as new Medicare regulations such as pay-for-performance and core measures are implemented.

Given the increasing demands on case management and the greater amount of documentation scrutiny, now is the perfect time to review the important elements of case management documentation.

The following are the most important items that a case manager should provide during a patient's initial assessment:

• Reason for admission; chief complaint, including if the patient failed outpatient surgery.
• Potential safety issues
• Patient support systems such as family and friends.
• Teaching needs and compliance issues.
• Initial determination of discharge needs.
• Clinical condition-determining need for medical care.  

Source: Case Management Monthly, July 2007

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