Case Management: Documentation Basics
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 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 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 (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 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 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 humanrights 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”.