August 2010Department of Elder Affairs Staff

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Present the components of the case record Present the components of the case

narrative Provide information to evaluate the quality

of the case narrative Detail covered/billable case management

and case aide activities

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Case Record Case Narrative

Record contains current client information, including: ◦ Eligibility documents, level

of care determinations◦ 701B assessment,

physician referrals◦ Care Plan◦ Case narratives◦ Service Authorizations◦ Budget Form◦ Signed forms (release of

information, grievance/fair hearing and provider choice, etc.)

Narrative contains a signed and dated note of each case management activity on behalf of the client, including:◦ Documentation of how care

plan needs are addressed◦ Documentation of completed

701 B (initial and annual)◦ Client contacts (phone calls

& face to face visits)◦ Documentation of service

receipt, service satisfaction & barriers to services

◦ Documentation of any client changes

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Case Record Case Narrative

Record contains current client information, including: ◦ Eligibility documentation◦ 701B assessment◦ Care Plan◦ Case narratives◦ Service Authorizations◦ Signed forms (release of

information, grievance, etc.)

◦ HCE: HCE Financial Worksheet and DOEA Notice of Case Action

◦ ADI/CCE: Co-Pay Assessment

Narrative contains a signed and dated note of each case management activity on behalf of the client, including:◦ Documentation of how care

plan needs are addressed◦ Documentation of completed

701 B (initial and annual)◦ Client contacts (phone calls

& face to face visits)◦ Documentation of service

receipt and barriers to services

◦ Documentation of any client changes

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The DOEA 701B assessment instrument is the foundation for writing a justifiable case

narrative. The case note should not be an essay repeating verbatim everything covered on the 701B; it should be a summary of the interview with the client and any observations of facts not captured in the assessment.

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When Type Activity Program

MW MonthlyTelephone or Face-to-face

Assess Client Status

ADA (Telephone), ALE (Face-to-face)

GR Monthly Telephone or

Written Correspondence

Confirm Caregiver Eligibility

HCE*

MW Quarterly Face-to-face Care Plan Review ALE, ADA

GR Semi-annual Face-to-face Care Plan ReviewADI, CCE, HCE (LSP and OAA Case Managed Clients)

Annually Face-to-faceAssessment/Reassessment

ADA, ALE, ADI, CCE, HCE (LSP and OAA case managed clients)

GR 14 Business* Day Follow-up

Telephone orFace-to-face

Service Initiation or Referral

ADI, CCE, HCE (LSP and OAA Case Managed Clients)

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* This can be done by a case aide with CM supervision .

Case narratives must contain the case manager’s observations of the client: ◦ What did you see in and around the home?◦ What did the client or the caregiver say? ◦ How did the client appear?

Note: Observations are based on FACTS.

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1. Client’s hygiene and grooming2. Client’s dress3. Client’s facial expression/affect 4. Client’s mannerisms5. Client’s response to others or to activities6. Client’s interaction with the case manager

or service worker7. Caregiver changes8. No significant changes with client or

caregiver

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The note describing the initial client visit or annual visit typically will require more detail than any other narrative that follows.

A note for a subsequent call or visit will focus on what has changed since the last contact.

Document actions taken to resolve issues.(IF IT IS NOT WRITTEN, IT NEVER

HAPPENED! )

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Type of Contact◦ Face-to-face (Where? Client home? ALF? etc.)◦ Telephone call, others

Purpose of Contact (to provide case management activity)◦ Annual, quarterly ,semi-annual, monthly or 14-day

follow-up◦ Client requested case management service◦ Referral made on the client’s behalf◦ Additional action taken to resolve issues

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Example: Client Changes

◦ Caregiver related◦ Emotional◦ Environmental◦ Financial◦ Physical◦ Social◦ Service related◦ Mental

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Example: Services

◦ Are services in place?◦ Is the client satisfied with service(s)? If not, why

not?◦ Have service needs changed?◦ Always document any and all referrals made on

the client’s behalf as well as the coordination/ facilitation of those referrals.

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Assessment notes provide clarification and any additional relevant information not covered in the 701B

Assessment notes cover all contacts and visits made in completing the assessment

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Service/Referral Satisfaction Quality of Service Quality assurance interviews

a. Rapport with service worker(s)b. Service worker attitudec. Service worker complianced. Service worker dependabilitye. Client/Caregiver evaluation

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Monitor client changes

Monitor receipt of, and satisfaction with, services

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Purpose is to confirm that the caregiver provided care to the client during the month.

◦ Caregiver may sign a form attesting to eligibility each month and submit it to the case manager.

◦ Confirmation may be made by telephone contact with the caregiver and documented in the narrative.

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Monitor continuity of services Monitor that client needs are being met Monitor client changes to make sure service

increases or decreases are warranted Authorize services as appropriate based on

need◦ Note: Any case notes regarding a change in the

care plan must include a notation by the case manager that the recipient is in agreement with the change.

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Address each problem/gap listed on the care plan Describe progress, barriers, problems and gaps Monitor continuity of services Monitor that client needs are being met Monitor client changes to make sure service

increases or decreases are warranted Acknowledge client/caregiver improvements and

the corresponding service changes or termination Authorize services as appropriate based on need

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Reassessment notes provide clarification and additional relevant information not covered in the 701B

Reassessment notes cover all contacts and visits made in completing the reassessment

Reassessment notes cover any changes from the previous assessment and any other significant changes◦ Updated assessment notes are produced when

there has been a significant change in the client’s condition outside of the regularly scheduled assessment dates

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At the end of your note, ask the following: Does the note justify the time billed?

If not, why not? What should be included or left out? Did you record the actual times spent and units of

service in the case note?

Note: Travel time and time spent documenting the case note are included in the note entry.

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Reimbursable Activities Reimbursable Activities (not specifically addressed)

1) Assisting applicants with enrollment and the Medicaid eligibility application process (if applicable)

2) Conducting and reviewing client assessment and reassessment for service needs

3) Developing and reviewing plans of care4) Arranging for service delivery5) Following up and monitoring service provision

and quality of services6) Recording case management activities in the

recipient’s record7) Recipient visitation8) Telephone, travel time and recording of progress

notes associated with billable activities9) Case closure and termination*

Prior authorization documents, warranty information on equipment purchases, price quotes, assistance with grievance process.

Client specific inter-agency consulting/staffing/communicating (examples: medical professionals, provider agencies, other case management agencies/their case managers, other external entities)

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•MW cannot bill after date of death or after nursing home/hospital entry. GR has 60 days after date of death.

Reimbursable Activities Reimbursable Activities (not specifically addressed)

1) Assistance with implementing plans of care

2) Oversight and supervision of provider training activities

3) Paraprofessional tasks intended to maximize productivity of case managers

4) Delivery of supplies and equipment to persons when shipping cannot be arranged*

5) Assistance with paying bills*

6) Assistance with accessing medical and other appointments*

Contact with persons to monitor service receipt and satisfaction

Documentation of activities in case record

Telephone and travel time associated with billable case aide activities

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* ADI, CCE, HCE, and LSP and OAA case management only

There may be additional requirements based upon the program. Be sure to include required documentation.

EVERY contact on the client’s behalf is recorded in the case note.

IF IT IS NOT WRITTEN, IT NEVER HAPPENED! If you are unsure, refer back to the DOEA

Programs & Services Handbook or the Medicaid Waiver Handbooks.

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Case notes should not be repetitive or contradict previously stated documentation. They should provide a fresh picture of the client’s current condition.

Keep in mind that what you write down can potentially be seen by a client, caregiver or other provider.

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1. Summers, N. (2001). Fundamentals of Case Management Practice Belmont, CA: Wadsworth/Thomson Learning.

2. Medicaid Waiver Handbooks3. DOEA Programs and Services Handbook

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