Nurse Case Manager's
  Documentation

Greater emphasis has been given to the role case managers play in the provision of patient care as a result of the redesigning, reengineering, or restructuring of healthcare delivery systems. This change has increased the level of importance of documentation. Documentation has become even more important in institutions that developed and implemented new patient care delivery models such as case management, care management, integrated care, and collaborative care. The main reason behind the increased importance of documentation is related to the changes that have occurred in the role of the registered professional nurse and social worker, particularly the introduction of the role of case manager.
     
The creation of the case manager's role has pressured healthcare providers, nurses, and others to rely more on some of the important functions nurses and social workers play in the delivery of patient care, which have historically been ignored. These functions include but are not limited to the following: These functions have been emphasized greatly in the job descriptions and the roles and responsibilities of case managers in a variety of institutions and patient care settings.

IMPORTANCE OF DOCUMENTATION

Case managers view documentation as an important aspect of their role (Case Manager's Tip 1). Documentation reflects their professional responsibility and accountability toward patient care. In its Standards of Clinical Nursing Practice, the American Nurses Association (1991) identifies documentation as an integral part of its six standards of care (Table 1). Bower (1992), Cohen and Cesta (1997), and Tahan (1993) also identified documentation as an important role function of case managers. There are several factors that increase the importance of case manager documentation, including the following:
  1. Professional responsibility and accountability to patient care
  2. Communication of the case manager's judgments and evaluations
  3. Evidence of case managers' plans of care, interventions, and outcomes
  4. Legal protection; valuable evidence
  5. Standards of regulatory agencies (e.g., the U.S. Department of Health and Human Services, the Joint Commission on Accreditation of Healthcare Organizations [JCAHO], the Commission for Accreditation of Rehabilitation Facilities [CARF], National Committee of Quality Assurance [NCQA], and the Utilization Review Accreditation Commission [URAC])
  6. Healthcare reimbursement (e.g., the diagnosis-related group [DRG] system, managed care organizations, and third-party payers)
  7. Supportive evidence of quality of patient care

ROLE OF CASE MANAGERS IN DOCUMENTATION

Documentation by case managers is extremely important because it is the only concrete evidence of their role in the provision of patient care. Case managers' documentation in the medical record should reflect the case management steps discussed in Section 1, Chapter 3 , the utilization management activities discussed in Section 3, Chapter 1, and the transitional planning/ discharge planning functions discussed in Section 3, Chapter 2. It should include documentation related to the following areas:

  1. Method of patient referral for case management services
  2. Patient screening for appropriateness for case management services
  3. Assessment of needs
  4. Identification of the patient's actual and potential problems
  5. Establishment and implementation of the plan of care, including the transitional plan
  6. Facilitation and coordination of care activities, including the resource/utilization management activities
  7. Patient and family teaching
  8. Patient discharge and disposition
  9. Evaluation of patient care outcomes
  10. Variances in patient care
    11.
 Appendix 1 at the end of this chapter presents an example of a case manager's documentation record.

Modes of Patient Referral for Case Management Services
Patient referrals for case management services may take place in three different ways. The first is a direct referral by a healthcare provider such as the primary nurse, private physician, consulting physician, house staff, nurse practitioner, physician assistant, social worker, or physical therapist. Personnel in the emergency department, doctor's office, or the admitting office could also refer a patient for case management services. The second is referral by the patient/family themselves, particularly if they were familiar with the case management process from previous encounters. The third method of patient referral is not a true referral. The case manager may elect to screen all new admissions and identify those who could benefit from case management. In home care settings and insurance companies, case managers may follow all patients regardless of the seriousness of the episode of illness.
     
In most institutions the case management referral process is preidentified by healthcare administrators and nursing executives in a policy, procedure, or protocol and made clear to all healthcare providers through education and training. Referrals are usually made based on prospectively established criteria similar to those discussed in Section 1, Chapter 3 (see Section 1, Chapter 3 Box 3-1).
     
The case manager's documentation (Case Manager's Tip 2) should include how the patient has been referred for case management services, who made the referral, the reason(s) for the referral, and the date and time of the referral. If no referral is made and the patient has been identified by the case manager when screening the new admissions, then the case manager's documentation should indicate so.
     
In some care settings, referrals for case management services by other providers may not exist. Examples are managed care organizations, in which case managers function as gatekeepers and demand managers, and telephonic case management, in which case managers function as triage nurses. In both settings the patient or family member/caregiver triggers the referral and the case manager completes it by connecting the patient with the appropriate healthcare provider or setting. The interaction between a patient/caller and the case manager in telephone triage/case management is limited in time, assessment process, and interventions given. Documentation in these situations is important for reducing legal risk. It should include a summary of the telephone conversation, the assessment made, the actions taken by the case manager, and the outcomes of the telephone call (Case Manager's Tip 3).

Patient Screening for Appropriateness for Case Management Services
However the referral is made, the case manager has to conduct a patient/family screening to determine appropriateness for case management activities. A decision regarding the patient's need for case management is made based on the "criteria for patient selection into the case management process" discussed in Section 1, Chapter 3 (see Section 1, Chapter 3 Box 3-1,). Some of these criteria are patient's acuity, age, complexity of diagnosis and medical condition, teaching needs, discharge/transitional planning, noncompliance with treatment regimen, insurance coverage, social complexity, and financial status.
     
When patient screening is completed and case management services are deemed appropriate, the case manager then writes an intake note in the patient's record explaining that the patient is accepted into the case management process (Case Manager's Tip 4).

Assessment of Needs
Screening of the patient/family for case management services and the initial assessment of needs are usually completed concurrently by the case manager because they are interrelated. The assessment of patient/family needs is made during the case manager's first encounter with the patient/family. Careful assessment and documentation of the patient's/family's needs can enhance the effectiveness of case management. Documentation of the initial assessment of needs by the case manager is a more detailed extension of the intake note (Case Manager's Tip 5). Both notes are usually completed consecutively, and in most cases one note is written combining both intake and assessment.
     
The case manager's documentation should not include a thorough health history or a physical examination. A statement indicating that the medical record, including the patient's history and physical assessment (assessments that are completed and documented by other healthcare professionals, including the primary nurse and the physician), has been reviewed by the case manager is of equal value and importance. However, the initial assessment note should reflect any significant abnormalities and problems identified by the case manager that would dictate the plan of care, the interventions/treatments, and management of the patient's needs.

Identification of the Patient's Actual and Potential Problems
Identification of the patient's actual and potential problems is the starting point for establishing the patient's plan of care. Accurate and comprehensive identification of these problems has a significant effect on patient care outcomes. Thoroughly examining the patient's medical record, in addition to interviewing the patient and family or caregiver, makes it easier for the case manager to prioritize the patient's needs that should be stated in the patient's record as actual or potential problems. Regardless of the patient's condition, needs, and chief complaint, the case manager's documentation of the patient's actual and potential problems almost always include problems related to the following:
  1. Patient/family teaching
  2. Discharge planning and disposition
  3. Need for postdischarge services
  4. Financial status
  5. Social support systems
  6. Clinical condition (i.e., signs and symptoms)
 The problems identified by case managers with regard to the complexity of patient/family teaching needs, discharge planning, and the absence of a social support system should be clearly and thoroughly documented in the patient's medical record.
     
For example, an elderly insulin-dependent diabetic patient who is legally blind and unable to self-administer insulin and who is admitted for uncontrolled diabetes cannot be discharged from the hospital before ensuring that he or she has a safe mechanism in place for administration of insulin injections. Another example is a businessman who is newly diagnosed with myocardial infarction and who is going to be started on cardiac medications for the first time. This patient may not be discharged unless patient teaching is completed or visiting nurse services are arranged for postdischarge follow-up and the patient discharge is deemed safe. Case managers are well trained in how to be proactive planners, particularly in how to meet the discharge planning and teaching needs of their patients before discharge.
     
The documentation of the case manager's assessment of the needs of these two patients on admission should include the potential problems regarding discharge planning and complexity of patient teaching. The plans of care developed should be reflected in the documentation, particularly how the identified needs will be met before the patients' readiness for discharge. Problems similar to the ones discussed in these examples may delay the patient's discharge. Careful documentation of these problems by case managers helps to justify the delay for administrators, insurance companies, and so on. This kind of documentation also justifies the patient's need for services after discharge (i.e., home care). Managed care organizations usually look for such documentation in the medical record, which justifies the need for intensive services, when conducting medical record reviews or making decisions about whether to authorize services.

Establishing and Implementing the Plan of Care
Planning patient care is a key element in the role of case managers. Accurate and careful planning based on the data collected during the initial screening and assessment of patients, as well as the appropriateness of the identified actual and potential problems, enables case managers to provide individualized, efficient, and high-quality care. The plan of care is extremely important because it serves as a communication tool for everyone involved in patient care. Articulating the plan of care in writing and making it clear to all those involved in the provision of care promotes continuity and consistency of care and enhances its efficiency and effectiveness.
     
Case managers are responsible for making sure that the written plan of care includes the patient's actual and potential problems and/or nursing diagnoses, the expected/desired outcomes of care, and the interventions/treatments needed to meet the expected outcomes (Table 2). It is important for case managers to document in the patient's record the patient/family agreement to the plan of care as discussed on admission and at the time the initial assessment of patient's needs is completed. Documenting that the goals of treatment are collaboratively set with the patient/family, the case manager, the attending physician, and others involved in the care is essential. This improves compliance with the JCAHO standard of patient's rights and continuum of care standards.
     
The case manager should document the goals of care to be met both before and at the time of discharge. These goals are the expected outcomes of care agreed on with the patient and family and the interdisciplinary team. The expected outcomes of care should be documented following a specific format (Box 1) and focusing on specific elements (Case Manager's Tip 6).
     
Case managers individualize the treatment plan and nursing interventions based on the signs and symptoms evidenced in the patient's condition. In addition, they include interventions that prevent any undesired symptoms or untoward outcomes. Case managers formulate interventions that are specific, realistic, individualized, patient/family oriented, and based on the signs and symptoms of the disease or the goals of treatment.
     
Documentation in the plan of care should reflect the case manager's ongoing evaluation of the patient responses to treatment and the required revisions in the plan of care as necessitated by the patient's responses.
     
Case managers are also required to reassess the patient and family on a continuing basis, evaluate the patient's condition for any improvements or changes, follow up on the appropriateness of the treatment and nursing interventions, and identify any new problems that may have arisen and ensure their inclusion in the plan of care. When the patient reassessment is completed, the case manager is expected to write a reassessment note in the patient's record (Box 2). It is recommended that case managers who work in acute or subacute care settings write a minimum of three reassessment notes for every patient each week of hospitalization. In long-term care settings, one reassessment note every week is considered appropriate. However, in ambulatory care settings such as clinics and home visits a note is recommended for every encounter with the patient. In telephonic case management, a reassessment note is completed every time the case manager makes a return or follow-up call to the patient or caller. In addition, a reassessment note is suggested as necessitated by the patient's condition.

Facilitation and Coordination of Care Activities
Because case managers are held responsible for coordinating and facilitating the provision of care on a day-to-day basis, their documentation in the patient's record should reflect these functions. Such progress notes include facilitation and coordination of care activities such as the following:
  1. Scheduling and expediting of tests and procedures and prevention of any delays
  2. Patient care-related conferences with the family and the interdisciplinary team
  3. Coordination of complex discharge/transitional plans
  4. Preparation of patients and families for operative procedures
  5. Transition of patients from acute to subacute or long-term care settings
  6. Consultation with other healthcare providers
  7. Ongoing communication with managed care organizations
  8. Utilization of resources and related authorizations by managed care organizations
  9. Referrals made to other providers or care settings
 Patient and Family Teaching
Case managers are responsible for supervising the patient and family teaching activities. This role responsibility should be evidenced in their documentation. Case managers make sure that patient/family teaching is included in the plan of care and appropriately documented in the patient's record. They document all of the patient/family teaching activities they conduct (Case Manager's Tip 7).

Patient's Discharge and Disposition
Patient's discharge and disposition are important responsibilities of case managers (Case Manager's Tip 8). Assessment of the patient's discharge needs starts at the time of admission and continues throughout the hospitalization until the patient is ready for discharge or transition to another level of care or another facility. Areas of documentation related to the assessment of patient's discharge needs are presented (see Box 4).
     
Documentation of discharge planning to support safe discharge is important because it may be scrutinized by peer review organizations (PROs) if the patient is readmitted with the same problem shortly after discharge. Such situations may increase the financial risk of the institution. If the patient is to receive home care services after discharge, the discharge note should then include the reasons for such services and what is expected to take place at home regarding the care of the patient. Because case managers discuss home care needs with home care planners or intake coordinators, it is suggested that such discussions and referrals be included in the discharge documentation.

Evaluation of Patient Care Outcomes
Evaluation of the patient's responses to treatments is essential for better decision making regarding the patient's progress and discharge. Progress notes of case managers should reflect documentation of the patient's status in relation to the desired outcomes established at the time of admission and proactively identified in the plan of care. The frequency with which case managers document patients' progress and responses to treatments depends on the institutional policies and procedures regarding documentation, the charting system, the type of treatments and nursing interventions needed by the patient, the standards of care, and reimbursement requirements.
     
Case managers are also required to track variances of care and delays in achieving patient care outcomes (see Section 5, Chapter 2 for a detailed discussion on variance). They are cautioned not to document any subjective judgments or system and practitioner variances because they increase the institutional liabilities.

Documenting Variances
When documenting the occurrence of a variance, the case manager should describe the event as specifically as possible. The variance should first be categorized at its highest level (e.g., internal system, external system, patient, family, or practitioner) (Box 5). Once the highest category has been identified, the case manager should then drill down to the next level. For example, the case manager may have identified that there is a delay in a patient receiving a computed tomography (CT) scan. This would be considered a "system variance," meaning that an issue related to the organization's own internal system processes caused the delay. Once the delay has been identified as "internal system," the case manager should then categorize it as "CT scan delay." Finally, the case manager will want to determine the cause or reason for the delay. This would be the final and most detailed level.
     
When possible, a prospective list, such as the one in Box 5, should be used by all of the case management staff so that staff members who are identifying variances are doing so in a consistent manner. The list should reflect all potential variances and should be as specific as possible. It can be coded and automated in a database. In this way, the case manager need only identify the variance by its code number (Case Manager's Tip 9).
     
By keeping the variances as specific as possible, and by creating the three-tiered system of identification, reports can be generated that will reflect any level of detail required. For example, a particular clinical department may want to know first how many total "patient-related" variances it may have had during a specific period. Then that department may want to know how many of each type. Finally, it may decide to focus on specific patient-related variances and will want to know the reasons for these variances. Automating the standard list and tracking of variances makes these reports less time consuming and easier to generate.
     
During documentation of the variances, the case manager should remember that the "system" and "practitioner" variances SHOULD NEVER be documented in the medical record. These categories of variances are legally protected by being part of the "quality management" initiatives of the organization and considered confidential and privileged information. Conversely, patient and family variances should be documented in the medical record as they relate to clinical and/or psychosocial issues that will need to be clearly communicated. The case manager should always follow the policies and procedures of the organization as they relate to documenting variances in the medical record. If the variances are warehoused in a database, this too will be protected under the quality umbrella.
     
A variance should be documented as soon as it is identified. If the variances are being entered into a database, the database will be current and the information in it will reflect "real time" issues. If the variances require immediate intervention, the case manager should document the actions taken to correct the situation in the appropriate location as per their policies and procedures. For example, if the patient had a clinical complication such as an infection, the case manager should document this variance in the database and in the medical record. The medical record documentation should reflect the change in the plan of care (medical and transitional plan) that was made in response to the infection, as well as the expected increase in length of stay, if appropriate.

CHARTING BY EXCEPTION

Charting by exception is a system for documenting against a predetermined, standardized set of expected outcomes. The system uses a number of tools, including standardized clinical/case management plans of care such as clinical paths or clinical practice guidelines. Fundamental to the process of charting by exception is the need to have predetermined outcomes against which the practitioner documents. The prospectively identified outcomes are evaluated at predetermined time intervals. The time intervals are specified in the case management plans or pathways. The practitioner assesses the patient and evaluates whether the outcome has been achieved. If the outcome has been achieved, then the practitioner needs only to time and initial the outcome. This indicates that the outcome has been met.
     
For a charting by exception system to be effective, the following assumptions must be made: When charting by exception, the expected outcome to be achieved is evaluated based on an (re)assessment of the patient. The assessment may include either a review of the patient's laboratory values, a physical assessment, an evaluation of educational outcomes, or direct reporting from the patient, all depending on the specific outcomes in review. If the patient has met the outcome as stated in the clinical practice guideline, the case manager initials the outcome indicating that it has been positively met and no further action is needed.

When Outcomes Are Not Met
Charting by exception systems require additional documentation only when an outcome has not been met. Therefore if an outcome is not met as per the patient assessment and evaluation, additional documentation is required. The unmet outcome is considered a variance. The variance is the actual outcome that was achieved by the patient. The actual outcome (variance) is then documented in the designated "variance" column in the case management plan or clinical pathway. Additional documentation of variance in the medical record must include a description of the variance and the action plan executed to correct the situation. Sometimes variances require a complete revision of the plan of care depending on the changes in the patient's medical condition, such as intubation and use of mechanical ventilation because of respiratory arrest.
     
Every time case managers identify a variance, they must return to their variance documentation system (e.g., automated variance list) to log in the variance and the reason it occurred. This documentation is important because such data are essential for enhancing the case management model and the system or processes of patient care delivery.

Charting by Exception Sample When Outcome Has Been Met
     
Clinical practice guideline for thoracic laminectomy
Operative day
Intervention Expected outcome Assessment/evaluation
Assess abdomen every eight hours Abdomen soft 9/1/03
Check for bowel sounds, distension Bowel sounds
positive
No distension		 10 AM AB

AB has placed her initials in the "Assessment/Evaluation" section of the guideline. Her initials indicate that the patient has met the outcome of "abdomen soft, no distension, bowel sounds positive." In this example, no further documentation is necessary.

Charting by Exception Sample When Outcome Has Not Been Met
     
Clinical practice guideline for thoracic laminectomy
Operative day
Intervention Expected outcome Assessment/evaluation
Assess abdomen every 8 hours Abdomen soft 9/1/03
Check for bowel sounds, distension Bowel sound positive
No distension		 10 AM
Abdomen distended, bowel sounds positive. Patient experiencing some discomfort. MD notified. AB

In this example, the expected outcome of "no distension" was not met on the operative day. Because the outcome was not met, the case manager needed to document what the actual outcome was and what his or her intervention was regarding it. If the unmet outcome resulted in an extension in the length of stay and/or a quality issue, the unmet outcome must also be documented as a variance.

DOCUMENTING PATIENT EDUCATION

The case manager's role in patient education may be one of educator and/or coordinator. In some models the case manager may develop an educational plan of care, perform the educational interventions, and monitor the educational outcomes. In other models the case manager may be coordinating the educational plan and outcomes but may not be directly involved in the actual educational process with the patient.
     
In any case, the best way to plan, evaluate, and monitor patient education and the outcomes of a patient education plan is through a charting by exception system. As the patient's educational plan is created, expected outcomes should be developed that correlate with each educational intervention. In this way, the case manager can monitor against the achievement of the expected outcomes and update the plan or intervene as necessary.

Educational Outcomes Must Be Measurable
Similar to other types of patient care outcomes, all identified educational outcomes should be measurable. For example, was the patient able to "return demonstration" of what he or she was taught? Or, was the patient able to verbally repeat back the given instruction? These expected outcomes should be prospectively included in the plan, and the case manager or patient educator should chart against them. Whenever a patient is unable to meet an expected outcome, the case manager must revise the plan to reflect new interventions that address the patient's inability to meet the expected outcome and strategies to meet the outcomes at a later time. Also included should be "why" the patient was unable to meet the outcome, and the plan should reflect a change in response to the unmet outcome. In some instances it may be appropriate to refer to a family member or significant other when planning and providing patient education.

Patient Education and Continuum of Care
The case manager should always consider the continuum of care in any educational plan. If the patient is in the acute care setting, the case manager must ensure that the educational plan safely transitions the patient to home or to another level of care or setting. Whenever possible, the educational outcomes that have been achieved, as well as those that have not been achieved, should be communicated to the providers in the setting to which the patient is transitioning.

Charting by Exception Sample of Patient Education When Outcome Has Been Met
     
Clinical practice guideline for asthma
Day 1
Intervention Expected outcome Assessment/evaluation
Instruct patient in use of metered dose inhaler (MDI) and spacer Patient is able to return demonstration of proper use of MDI and spacer 9/10/03
2 PM, RM

RM has placed her initials in the "Assessment/Evaluation" section of the guideline. Her initials indicate that the patient has met the outcome of "able to return demonstration of proper use of MDI [metered dose inhaler] and spacer." In this example, no further documentation is necessary.

Charting by Exception Sample Patient Education When Outcome Has Not Been Met
     
Clinical practice guideline for asthma
Day 1
Intervention Expected outcome Assessment/evaluation
Instruct patient in use of MDI and spacer Patient is able to return demonstration of proper use of MDI and spacer 9/10/03
2 PM
Unable to return demonstration of proper use of spacer. Will reinstruct later today. Patient properly using MDI after repeated instruction. RM

In this example, the expected outcome of "able to return demonstration of proper use of MDI and spacer" was not met when RM evaluated the outcome at 2 PM of Day 1. Because the outcome was not met, the case manager needed to document what the actual outcome was and what her intervention was regarding it. If the unmet outcome resulted in an extension in the length of stay and/or a quality issue resulted, the unmet outcome would also need to be documented as a variance. Unmet educational outcomes may trigger a need for postdischarge services that may not have been evident at the time of the patient's admission to the hospital. Timely evaluation and documentation of educational outcomes is important because it provides evidence that justifies the need for follow-up services, ensures certification for these services, and ensures that the patient's plan of care remains appropriate throughout the care episode.

CASE PRESENTATION

Documentation by case managers is essential to patient care because it eliminates confusion and uncertainty from the plan of care and promotes its understanding by all of the healthcare providers involved in the provision of care of the particular patient. Documentation reflects the professional responsibility and accountability of case managers toward patient care and provides concrete evidence of their role in the provision of care. To help the reader better understand the case manager's role in documentation, the rest of this chapter is a discussion around a case presentation of an elderly patient with exacerbation of heart failure who needed acute care (Case Study 1). Although this case presentation focuses on acute care, the concepts and skills discussed may be applied in any care setting.
     
Documenting the patient's care in the medical record is an important means of communication between healthcare professionals. It eliminates misunderstanding and improves awareness of the patient's condition, plan of care, and responses to treatments. Case managers' documentation is necessary to the understanding of their role in patient care. The case study and excerpts on documentation shared in this chapter are only examples of case managers' documentation. Case managers are advised to review the policies and procedures related to documentation that are available in the institutions where they work and make every effort to comply with those policies and procedures.

KEY POINTS
  1. Documentation by case managers is important because it is the only concrete evidence of their role in the provision of patient care.
  2. Documentation acts as a means of communication among healthcare professionals.
  3. Documentation improves awareness of the patient's condition, plan of care, and responses to treatments.
  4. Documentation by case managers should follow the case management process. For each step in the process, a note is expected.
  5. Case managers are responsible for supervising patient education. As part of this responsibility, they should ensure that the educational needs of the patient are planned and documented.
  6. Documentation of the discharge planning process is essential to the role of the case manager.
  7. The case manager may be responsible for documenting variances or for designing a process for documentation.
  8. Charting by exception is a system for documenting against a predetermined set of expected outcomes.
REFERENCES

American Nurses Association: Standards of clinical nursing practice, Kansas City, Mo, 1991, The Association.

Bower KA: Case management by nurses, ed 2, Kansas City, Mo, 1992, American Nurses Association.

Cohen EL, Cesta TG: Case management: from concept to evaluation, ed 2, St Louis, 1997, Mosby.

Tahan HA: The case manager in acute care settings: job description and function, J Nurs Adm 23(10)::53–61, 1993.

APPENDIX 2-1

CASE MANAGER'S DOCUMENTATION RECORD

This appendix presents an example of a case manager's documentation record. The use of a standardized record streamlines and improves documentation. The record acts as a trigger for better documentation. It also reduces the amount of time required for thorough documentation. Such records can be made flexible to fit the needs of case managers in any patient care setting.

Important Aspects of Documentation
Effective documentation provides a written record of the following items: EXAMPLE OF A CASE MANAGER'S DOCUMENTATION RECORD
Glossary     


Appendix A
Appendix B
Appendix C
Appendix D
Appendix E-1 Appendix E-2 Appendix E-3
Appendix F
Appendix G
Appendix H
Appendix I
Appendix J
Appendix K
Appendix L
Appendix M
Appendix N
Appendix O


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