Last Updated on July 3, 2023
Documentation is perhaps the most important part of case management. Documentation serves as the proof that services were rendered. Although we don’t like to discuss it, documentation is tied to the bottom line (payment) and is what keeps us employed.
Assessments
Assessments are used to gather basic information to
determine the needs of the client. Assessments also help determine if the
client is qualified for services. Some services, especially mental
health/disability services, have specific diagnostic requirements for admission
into the program.
Assessments contain information on the treatment history and
any medical concerns. Assessments can also obtain social and behavioral
history. Background information on psychiatric
hospitalization, legal involvement, and other health information is critical
for case managers to have in order to provide the best service possible. Case
managers pass this information on to direct service providers during the
referral process so they can determine if the client is appropriate for their
program.
Assessments are also helpful during the case assignment
process. After the intake, the agency can use this information help match the
client to a case manager that can best meet their needs. Some clients may
require or prefer specific characteristics in case manager such as gender or expertise
in a certain area. For example, a client may need a male case manager due to a
history of aggressive or inappropriate behaviors toward females. In addition,
each case manager has a different background or experience in other areas which
may make them a better fit with a certain client. Some case managers have more
experience with younger clients and may be better with children. The same may
be true for the older population. The information gathered from assessments is
important because they play a key role in the development of the treatment
plan.
Treatment Plans
Treatment plans serve as a blueprint that guides the
direction of client services. Information taken from assessments is taken to
determine what the client needs and what they would like to achieve. Of course,
this takes the form of specific goals and objectives. The treatment plan is
probably the most important document in the chart, as it dictates the
information that will be added to progress notes and quarterly reports.
Whatever is on the treatment plan must be reflected in the progress notes and
the quarterly reports.
Progress Notes
Progress notes (sometimes referred to as case notes) provide
the most up to date information on the services that have been provided and the
progress that have been made. Depending on the company policy, progress notes
usually need to be completed and put into the client file anywhere between 24
hours to five days after the service has been provided.
Progress notes are typically completed for every contact
made regarding the client. These contacts can be direct conversation with the
client either on the phone or face to face. Progress notes serve as a log or
journal of client and case manager activity. Progress notes provide a helpful
reference to provide information whenever there is an audit.
Progress notes provide insurance companies proof that
services have been provided. Of course, this is needed to justify payment for
services. Progress notes also documents progress towards treatment plan goals.
Quarterly Reports
Quarterly reports are a summary of services provided over a
three month period. Quarterly reports also demonstrate progress toward
treatment goals. The quarterly report often refers to information from case
manager progress notes as well as reports from service providers. Quarterly reports can also serve as an easy
reference for anyone covering the case. When a case needs to be covered when
the case manager is not available, one of the first documents reviewed is the
quarterly report. The quarterly should provide a snapshot of the goals and any
recent changes and the most recent status of progress.
Incident Reports
Incident reports provide critical information when there is
a serious event such as an injury, medical emergency, or death. In most cases,
incident reports should be completed within 24 hours of becoming aware of the
incident. Case managers are usually not involved in incidents are often
informed days after the incident has occurred. It is still the case manager’s
responsibility to provide a report as to what staff actions were taken and a
follow up plan. This information is sent to supervisors and any Quality Assurance
department staff. In some cases, state licensure and human
rights agencies may
be involved (Especially in client deaths). Most importantly, incident reports
initiates a chain of documentation on when the incident occurred and what
actions were taken all staff involved.
In, summary documentation is a critical aspect of case management
and any human service profession. The development of assessments determine eligibility
and planning services. Progress notes, quarterly reports, and treatment plans serve
as evidence that services have been provided. Documentation is what insurance
companies and other funding sources use to determine if they will cover
services. Because as the old saying goes: “If it isn’t written down, it didn’t
happen”.