Case Management

Tip: Don't include UM documentation in the medical record

Case Management Weekly, April 21, 2010

Establish a location for utilization management (UM) documentation that is separate from the medical record. UM documentation is not clinical documentation and should not be available to anyone requesting the medical record. The optimal site is an electronic system.

Update this document with additional medical necessity reviews after the initial assessment. Intervals of medical necessity evaluation may be determined by patient treatment and condition, or by department protocol.

For example, a patient undergoing a colon resection may require subsequent assessment two to three days after admission because the estimated length of stay could exceed two days. A patient being evaluated for potential abdominal surgery may require subsequent assessment the next day.

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 An answer to your question might appear in a future issue of Case Management Weekly.

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