Case Management Focus Documentation — The Defense YOU Need When Called Out

Sarasota, FL (WorkersCompensation.com) -- When was the last time you had a class on documentation? For many nurse case managers and other healthcare professionals, that class was probably taken during your initial training or at an in-service when the Electronic Health Record (EHR) was introduced into their organization.  

The way we document has changed, so a refresher is needed to ensure your documentation is in line with current practice. In this post, I wanted to share some tips you, as a licensed professional, can use to ensure your documentation is on target and expresses the information relevant to your practice.    

Key elements in case management documentation include client information, assessment findings, goals and objectives, intervention plans, progress notes, communication records, and closure summaries. As we know, things change. Review demographics with the patient/family at each entry to ensure the record is current. If there are changes, make sure they are made.  

Now that most healthcare systems are on electronic health records, many more people see your documentation than they used to. In addition to the healthcare team, the injured workers and their families read notes to try to understand what is happening. They read with interest what you say about them and how you say it. If they bring information that they say needs to be more accurate, inform risk management or your IT team as to how to correct it or note the discrepancies raised and why you feel your documentation is correct or in need of change.  

As patients and their families access the electronic health record, they may need an explanation of what was written. Take the time to review the documentation with them. Answer their questions. Educate them as to how to use the record. Write in plain language so non-medical readers can understand what was written. Use evidence so that healthcare team members understand the care you provided and that it is based on evidence.  

Some tips to improve your documentation 

• Keep your documentation clear and concise. Focus on the information pertinent to your client's goals. If you include less unnecessary detail, finding the information the reader wants in your notes may be more straightforward. 

• Provide details in your notes that will allow another professional to take over for you. They should be able to take your notes, understand what you are working on, and follow your care plan.  

• Be clear, concise, and objective. 

• Focus on relevant information and avoid unnecessary details that do not advance the point you are trying to express  

• Stick to facts and avoid opinions, judgments, and reactions. Consider how the client might feel if they read your notes. Use an example if you need to write a negative comment you think is essential to share in your note. If you can, quote the person. That shows the rationale for your action.  

• Include quotations when appropriate, and specify where information came from, such as client reports or medical records. 

• Document promptly. Ideally, document during or right after the encounter while things are still fresh in your mind. 

•  If you forget something, go back and add it. Note Late Entry before the comment and what it relates to so Someone can follow your thread.  

• Incorporate evidence and examples when appropriate. 

• Get feedback if you have questions about what you wrote. Ask Someone in your best interests to review your documentation and provide feedback. 

These tips are fundamental to documentation wherever you work. Before you document, check in with Risk Management if you have questions. The risk manager can advise you on how to document without implementing yourself.  

Remember, if you are called into a court of law as a witness, defendant, or expert, accurate documentation can mitigate risks and reduce the chance of a costly malpractice claim.  

Most lawsuits are filed years after the original accident. Your documentation is a reminder of what happened at the time.  

A well-documented record serves as evidence of treatment, care, and why you did or did not do as part of your work.  

All case managers should know the Case Management Standards of Practice that guide our practice. Attorneys will use them and view your documentation to them. If you are unaware of or have not reviewed them recently, get your copy at https://cmsa.org/about/standards-of-case-management-practice and review them often. Also, review and be familiar with your employer's policy and procedures for documentation.  

Case management topics on WorkersCompensation.com are brought to you by Paradigm. Paradigm does not have input into editorial decisions regarding Case Management Focus columns and any views expressed in such columns do not reflect the views of Paradigm or its employees.

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