Jun

03

Q&A: Case management documentation

By Case Management Weekly

Q: I am a case manager on a cardiac step-down unit. Our case managers’ work focuses primarily on l specific disease management and patient contact/education and nurse mentoring/chart reviewing, patient rounding, etc. We are very clinically focused.  
We don’t do utilization review (UR) or discharge planning. We face the issue of case manager documentation. Legally, what must we document?  

A: In this model, not doing utilization review allows the case manager to really focus on clinical progressions, which should be the focus of his or her documentation. The case manager should document how sick the patient is, and how the patient is progressing clinically each day. There’s no legal requirement for the case manager in this position to document, but there is a professional requirement to document the clinical progression as well as what the case managers taught the patient prior to discharge and how the patient responded. Every time they see, touch, or talk to a patient, the case managers should document.

This question was answered by Karen Zander, RN, MS, CMAC, FAAN.