Clear, appropriate CM documentation essential

Be especially careful when case is terminated

Documentation is a valuable communication tool throughout the case management process, providing an accurate record of the assessment, care plan, and execution of treatment and services. Through systematic collection of information about the service experience, the end results of care can be evaluated.

When case management services are terminated, for whatever reason, careful documentation also is essential. The documentation completed at termination must be factual, clinical, and devoid of any personal opinion or judgment. Case managers must take pains to ensure their documentation is objective and does not create a perception that would violate their role as advocates on behalf of the patient or client receiving services or have the appearance of bias.

The need for clear and careful documentation is underscored by the current definition (2002) of case management from the Case Management Society of America (CMSA). The CMSA describes case management as "a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes."

The key words of "assessment, planning, facili-tation, and advocacy" are the guiding principles for documentation, which begins when the relationship with the patient is established and continues through the course of treatment. Some case management providers may find it helpful to streamline documentation, even providing standardized scripts to guide case managers in the process. This might include, for example, a letter of introduction that clearly specifies the case manager’s role and relationship with the patient.

The rule of thumb is that documentation is just for the facts: The assessment is detailed, the plan is discussed, and what occurred is noted. The case manager’s own hunches and speculations generally should not be included. For example, phrases such as "the patient doesn’t want to work," or "the patient is uncooperative," do not belong in the documentation. Rather, the documentation content should consist of quoted statements and observable actions. An unbiased, factual assessment, with the suspension of judgment, should allow anyone to read the case documentation and understand exactly what transpired.

When case management is terminated, documentation should include the reasons why the relationship ended. The patient, the provider, or the payer may trigger the termination of services. Eight typical reasons for terminations are:

  • Death.
  • Relocation out of the service area.
  • Patient cannot be located.
  • The patient is not available for services for more than 90 days (e.g. institutionalization).
  • The patient is no longer in need of services.
  • Patient refuses further services.
  • Patient requests termination.
  • Patient refuses to cooperate with case manager in needed services.

Among these termination scenarios, some of the trickiest — particularly from the perspective of the documentation — are when the provider terminates because the patient is uncooperative or unpleasant; the patient refuses to comply with treatment; or there is an incident involving actual or threatened violence.

The case manager must guard against allegations of abandonment through careful assessment and documentation. Once services are begun with a patient, there is a duty to provide care. Once the relationship is started, any changes (such as the payer refuses to pay for more care), need to be noted. The case manager also must document efforts to assess whether the patient needs further services, and if so, what was done to ensure the patient will not suffer harm.

The documentation needs to reflect termination with reasonable written notice and with a plan for referral or other measures to meet the patient’s needs for care to avoid harm. A team care conference and careful discharge plan that is documented in detail are recommended.

Despite the emotional element in these termination scenarios, case managers must redouble their efforts to ensure documentation states the facts and only the facts. A good recipe for case management termination includes the following:

  • Assessment of no benefit/no need.
  • Documentation of discussion with patient.
  • Written notice, delivered.
  • Documentation of no further action needed.

All of the above is recorded in the patient’s record.

Careful documentation is far more than just the necessary paperwork. It is a complete, accurate, and factual account of the case from beginning to end. Strategies include careful and precise choice of words and full and complete recounting of events and outcomes.

The challenge for the case manager is to suspend emotional reactions and the tendency to ascribe blame, particularly when the relationship with the patient is difficult or uncomfortable. The reward, however, is to know that their case management responsibilities were discharged professionally, appropriately, and in keeping with their essential roles as advocates. This also is the best recipe for ethical and legal safety.

Diane Huber, PhD, RN, FAAN, CNAA, BC, is a professor at the University of Iowa (UI) College of Nursing, teaching case management courses. She also is an investigator at the UI Center for Addictions Research, Institute for Strengthening Communities. Huber has a secondary appointment at the UI College of Public Health (Department of Health Management and Policy). She is chair of the Commission for Case Manager Certification (CCMC), which has awarded the certified case manager (CCM) credential to more than 26,000 case management professionals since 1992. The CCMC is the first certifying body for case management professionals to be accredited by the National Commission for Certifying Agencies. URAC also has determined that the CCM credential is a recognized case management certification.

For more information or to obtain an application for the CCM, contact the CCMC at (847) 818-0292 or visit the web site at