What key elements should be included in case management documentation?

I understand that in many areas of case management, especially in the healthcare industry, documentation can feel very repetitive and often looked at as unimportant. While documentation can be a hassle sometimes, I do think it is important to recognize the value that it brings. When working on a case that was previously handled by another case manager, I find it very helpful when that case manager completes documentation appropriately in detail. I really appreciate the note in this article about aligning with the client's values. In the healthcare field, it can be easy to say and want to do what is best for the patient's health, but sometimes that is not what the client wants and we need to respect that, document that, and follow that.

I think we are at an inflection point in case management documentation. I've worked in multiple disciplines using case management. They are almost all program specific and/or driven by billing. Over the next couple years we are going to go from program focused to person focused, with an overarching theme of data sharing. Intake will be greatly shortened because more information will come from other sources. Medical and SDOH programs will be able to share information more seamlessly, and we will leverage master person indexes to keep information current. Patients will also be part of their documentation ecosystem with them being active participants in maintaining current information, and managing consent.

In property management, using case management is a great way to handle tenant conflicts. It's a structured and proactive approach to dealing with disputes. And here's the thing: case management doesn't stop once the conflict resolution plan is in place. We stick around, keeping an eye on things to make sure the solutions we agreed upon are actually working. It's all about making sure everyone's happy in the long run!

Key elements in case management documentation include client information, assessment findings, goals and objectives, intervention plans, progress notes, communication records, and closure summaries.

In case management documentation, the crux lies in articulating seamless collaboration and coordination. Drawing from personal experience, documenting collaborative efforts captures the essence of shared decision-making and ensures a holistic approach. For instance, detailing joint efforts with healthcare providers not only showcases a comprehensive patient care strategy but also exemplifies the coordination required for optimal outcomes. This personalized touch to documentation transcends the mundane, reflecting the intricate dance of collaboration that underpins effective case management.

It is important to provide real-time or near real-time documentation to minimize errors or omissions. Document the patient’s involvement in decision-making and consent for treatment, preferences, and any advance care planning discussions.

Envision a world where phrases like “patient-centered”, “meeting the patient where they are”, and “patient-focused” truly embody their meanings. In such a world, patients and clients are integral to every aspect of the process, from program design to evaluation. In this ideal scenario, we actively engage with our clients, seeking their input on what should be included in our documentation and respecting their preferences regarding what is documented about them. This approach not only empowers patients but also ensures that our services are tailored to their unique needs and comfort levels. Food for thought!