Case Management

Don't underestimate the importance of good documentation

Case Management Insider, January 19, 2016

It’s an unfortunate part of healthcare today—the lawsuit. Are you ready if one is filed against your organization?

You are if your documentation is in order, says Peggy Rossi, BSN, MPA, CCM, a consulting associate for the Center for Case Management in Wellesley, Massachusetts, in her regular director’s desk column for HCPro’s Case Management Monthly (CMM). When a case is long-forgotten, good documentation can help you recall what happened and ultimately may help defend you and your healthcare employer.

Under CMS’ current Conditions of Participation for discharge planning, a hospital must document the plan and have a solid process for developing those plans that is spelled out in writing.

If any of the required discharge plan documentation or details about the interactions with the patient and his or her family is missing, the organization may run afoul of those requirements, says Rossi. This failure can result in severe sanctions to the hospital, with the worst being exclusion from participation in the Medicare program, says Rossi. This means the hospital cannot be reimbursed for services provided to Medicare beneficiaries.

Not good news.

So this should give you some pretty good reasons to make sure that staff members at your organization are dotting all those I’s and crossing all those T’s.

After all, documentation may seem like a pain, but it is clearly a task that case managers performing discharge planning must take seriously and it must be performed after every encounter with a patient.
Remember, if it’s not in writing it didn’t happen, says Rossi.

Editor’s note: To read more of Rossi’s advice on a host of different topics check out her monthly’s Director’s Desk Column in CMM. Got a case management question for Rossi or any of our experts? Submit it to Kelly Bilodeau at

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