case noting a basic refresher course on case note documentation

1. Case Noting A Basic Refresher Course on Case Note Documentation

3. What is case management? Ongoing monitoring of services and service coordination Ensure that quality service is being provided Evaluating whether a service is effectively meeting the participant�s need Identify any changes in the participant�s condition or circumstances that would warrant an adjustment to the care plan.

4. Reflects what is happening with the plan Provides required documentation to support required care management contacts as directed by the State Provides a measure of protection Why are Good Case Notes So Important?

5. How much care management is provided to COP-W/CIP II participants? According to the Bureau of Long Term Support (BLTS), an average of 2 hrs/month of care management is provided to COP-W/CIP II participants each month Each case is individual, and how much care management is provided to a person depends upon the person needs, his/her circumstances, stability of care providers, etc. Case notes can also help you track how much time you are spending on a case

6. State Requirements The participant record must reflect a frequency and intensity of contacts to support reported units of service and minimum contact requirements. Documentation/case notation of all contacts must reflect allowable activity and indicate that the activity is related to the participant�s individual needs.

7. State Recommendations A case note should: Cite the date Identify the people and relationship Identify the type of contact � Face to face, phone conversation, etc. Describe the event Recount the transaction Demonstrate how the contact relates to the ISP Describe how the issue was resolved, and/or next steps

8. Case Noting with Outcomes in Mind Case notes should reflect any work toward implementing, monitoring, or any changes in an outcome. Case notes should be written that reflect the: Progress or tracking of events Who is responsible for doing what

9. Case noting with Outcomes in Mind continued Case notes will provide documentation that the care manager is focusing on the right thing � keeps you on target It�s not about �checking in� � it�s about �What am I checking on�.

10. Case Note Differences Case noting a contact Phone, face-to-face, correspondence Tracking the flow of events, outcomes Case noting for documentation purposes Medicaid denials, cost share verification, paperwork

11. Reasons to Record All Activity Leave a �paper-trail� Provide verification of activity Reminder to Care manager Help the worker testify Help the next worker Help co-workers and supervisors Contact compliance mandates

12. Warning Possible Liability Issue Recording a �to do� item in the case file and not following through Negative, biased, or prejudicial language

13. Keep in Mind If you didn�t write it down, no one knows it happened Your records might be viewed by: Judges Attorneys Participant Guardian State

14. Writing Recommendations Write in a style that is: Factual Objective; unbiased Specific Clear and to the point

15. Other Writing Tips Without jargon Don�t write so cryptic that no one one knows what you are writing Omit details of clients intimate lives that do not have an impact on care plan Avoid using medical diagnoses that have not been verified

16. Case Note Exercise Read the case notes provided Is the case note acceptable? Complete? Why or why not?

17. Case Note Exercise #1 6/5/06 Talked to Sue. She said things are going well.

18. Answer to Case Note Exercise #1 Answer: No Reason: Don�t know what type of contact occurred - a face-to-face?, telephone? Who is Sue? Limited information.

19. Case Note Exercise #2 6/5/06 Voice mail message from Margaret. She relayed that Mrs. Roberts cancelled the supportive home care worker today because she was not feeling well.

20. Answer to Case Note Exercise #2 Answer: No Reason: Who is Margaret?

21. Case Note Exercise #3 6/5/06 PC with Peggy O�Brian- SHC coordinator w/the agency We Do Everything. Peg relayed that Mrs. Roberts cancelled the SHC worker today because Mrs. Roberts was not feeling well. Peg relayed that Mrs. Roberts decided not to reschedule for assistance for another time this week. Mrs. Roberts said it was ok for her worker to go to Mrs. Robert�s apartment next week, same time.

22. Case Note Exercise #3 Answer: Yes � this case note is acceptable.

23. Case Note Exercise #4 6/5/06 Talked to Mrs. Roberts. She said things are going well. Son and his family visited over the weekend. Had a nice time.

24. Case Note Exercise #4 Answer: No Reason: Don�t know what type of contact occurred � face-to-face? telephone? No documentation to suggest there was discussion about the participant�s services, health, outcomes that may be working on, etc.

25. Case Note Exercise #5 6/5/06 PC w/ Mrs. Roberts. She said things are going well. Son (Tom) & his family visited on Saturday afternoon � she said she enjoyed seeing the grandchildren. Had a nice time. She reports feeling good. Carrie (SHC worker) and Pat (PCW) still arriving as scheduled- she reported no problems w/ their assistance. HDM�s still arriving as scheduled- said she is looking forward to what�s on today�s menu- polish kielbasa. Scheduled home visit for 6/7/06 at 1:00 p.m.

26. Case Note Exercise #5 Answer: Yes � this case note is acceptable.

27. Case Note Exercise #6 6/5/06 PC w/ Mrs. Roberts. She said she was fine. Made appt. to visit her tomorrow at her apartment at 10:00 am.

28. Case Note Exercise #6 Answer: Yes � this case note is acceptable.

29. Case Note Exercise #7 6/5/06 HV w/ Mrs. Roberts. Nice visit. Things are status quo.

30. Answer to Case Note Exercise #7 Answer: No Information is limited. No information given regarding what was discussed/learned during home visit. No information given regarding the service plan, person�s health, outcomes, etc.

31. Case Note Exercise #8 6/5/06 HV w/ Mrs. Roberts. She looked awful-clothes dirty, hair dirty, hair messed up. She stunk. The apartment smelled liked pee. As usual, she complained of not feeling good. Told her to go see her doctor. Will call SHC coordinator to find out if she knows anything about why Mrs. Roberts stinks.

32. Answer to Case Note Exercise #8 Answer: No. Reason: Unprofessional, biased

33. Case Note Exercise #9 6/7/06 HV w/ Mrs. Roberts. Appearance unkempt- clothes stained, hair dirty & uncombed. Noticeable body odor. Apartment appeared neat & tidy although urine smell detected. This is the first time this CM has noticed the urine smell or seen Mrs. Roberts in this appearance in the 2 yrs I have worked w/ her. Appeared alert & oriented during visit. Mrs. Roberts relayed her in-home workers have been coming regularly. Reviewed SHC/PCW work schedule calendar posted on wall. SHC worker was scheduled to arrive yesterday � June 6th .

34. Case Note Exercise #9 Continued� Mrs. Roberts confirmed the SHC worker was there yesterday - however noticed she could not recall SHC worker�s (Carrie L.) name, which is unusual for her. Had to remind her of SHC worker�s name. PCW is scheduled for tomorrow at 9:00 a.m. Still getting HDM�s � likes them. Wants them to continue. Noticed she was not wearing her Lifeline. Suggested she wear it for safety reasons. She said she puts it on after supper. Was able to observe her ambulate from chair to coffee table. Used walker � no problems w/ ambulation noted. Mrs. Roberts said she was �feeling good � but I�m so tired lately�. Asked if she has seen her MD lately.

35. Case Note Exercise #9 Continued� She said she has not seen her MD since her check up in the Feb. 2006. She said she talked to her daughter Jill about her health & Jill is making a MD appt. for her. She said Jill will be taking her to the appt. when it is made. Told her I would contact her in a few days to see if appt was made and to see if she needs any assistance. Said she is looking forward to the summer season. Apartment has a window air conditioner. Will call the SHC coordinator to find out if in-home workers have noted any changes in Mrs. Roberts appearance or health lately. Will ask if worker has noticed any incontinence problems when assisting with laundry.

36. Answer to Case Note Exercise #9 Answer: Yes � this case note is acceptable

37. Take aways Case notes are lengthy when they are needed to document all important information that was observed, or discussed Case notes can be short, concise when that is warranted The correlation between the amount of care management billed for a contact and what is documented in a case note.

38. Decisions, Decisions, Decisions FORMAT of CASE NOTES

39. Format Options Medicaid Approach P.I.O. Approach � Problem, Intervention, Outcome SOAP Approach � Subjective, Objective, Assessment, Plan

40. Medicaid Case Management Case Note Requirements Name of recipient The full name and title of the person who made the contact What the content of the contact was Why the contact was made How much time was spent The date the contact was made Where the contact was made *Source: (Wisconsin Medicaid Case Management Handbook)

41. Small Group Exercise

42. Small Group Exercise 6/14/06 Talked to Mary. She stated that Mrs. Smith could use more SHC hours. I told Mary that Mrs. Smith is just getting lazy � that she could do some of the work herself. Mary told this CM that Mrs. Smith is becoming more forgetful. I told Mary that Mrs. Smith probably has the early stages of Alzheimer�s.

43. Break

44. Answer to Small Group Exercise List of Problems With the Case Note What kind of contact occurred? Who is Mary? Opinionated Assuming Mrs. Smith has Alzheimer�s CM did not ask or document any conversation or questions she may have had regarding Mrs. Smith�s forgetfulness, need for additional hours

45. Rewritten Case note -Small Group Exercise

46. Trying to Keep Up Discussion How do you approach case noting? What is working? What�s not? What could you do better?

47. Case Note This 7 conversations in 15 minutes

49. Tips & Techniques to Consider Carry a note pad with you at all times Keep a note pad near your phone Save a half hour each day to do case noting Develop an agency protocol Set aside paperwork days and put it on your calendar Re-evaluate current forms/templates - are there things that could make them easier? Talk to a co-worker who does case noting well to learn from him/her Secure protected time Is it possible to turn your phone off for a half hour Say �no� to other tasks

50. Commonly Asked Questions and Answers Question 1 Does a care manager have to sign his/her full name or initials after each case note?

51. Commonly Asked Questions and Answers Answer For the COP-W/CIP II waiver program, the answer is no. However, for Medicaid care management, signing your full name or initials after each case note is required. If initials are used, a signature page with the care manager�s full name should be in the file Tip: make life easy on yourself. May wish to get in the habit of signing/initially each case note for all your cases, instead of trying to remember the different rules for the different programs.

52. Commonly Asked Questions and Answers Question 2 Is it okay/acceptable to include multiple entries/contacts into one case note?

53. Commonly Asked Questions and Answers Answer Yes. � this is probably going to be ok � However, there is no specific documentation to indicate the specific time a care manager spent on each specific contact. Also, when there are multiple entries/contacts within a single case note, it is difficult to determine what type of contact occurred, and the content of the contact sometimes becomes scant and cryptic. Lastly, all the tasks completed are documented, and are waiver allowable.

54. Commonly Asked Questions and Answers Question 3 Is there a �correct� way of documenting my time? Should a care manager bill actual time for each care management contact? Should the care manager �round� up his/her time after each contact?

55. Commonly Asked Questions and Answers Answer A care manager should record actual time for each care management activity that is done. It is allowable to �round up� the care management time at the end of the month. Example: a care manager adds up all the minutes of care management he/she provided to a participant in a month and it is 42 minutes. Because HSRS is entered in 10ths, the amount of units billed to HSRS would be .7 It is incorrect to �round up� after each CM contact.

56. Billing in One-Tenth Hour Increments Time (in Minutes) Unit(s) Billed 1 � 6 min. .1 7-12 min. .2 13-18 min. .3 19-24 min. .4 25-30 min. .5

57. Billing in One-Tenth Hour Increments continued Time (in Minutes) Unit(s) Billed 31-36 min. .6 37-42 min. .7 43-48 min. .8 49-54 min. .9 55-60 min. 1.0

58. Commonly Asked Questions and Answers Question 4 What are billable care management tasks?

59. Commonly Asked Questions and Answers Answer Allowable care management tasks include those services listed in the Medicaid Waivers Manual � Chapter IV � page IV-22. These services range from reassessments, advocacy, the re-evaluation of the effectiveness of services and services providers, etc.

60. Commonly Asked Questions and Answers Question 5 What are non-billable care management tasks?

61. Commonly Asked Questions and Answers Answer As per Wis. Admin Code 107.32 (3) (a) 1-8: it is not allowable for a care manager to bill as care management: Diagnosis of a physical or mental illness Monitoring of clinical symptoms Administration of medication Client education and training Legal advocacy by an attorney or paralegal Supportive home care HHA or Personal Care

62. Ponder this If a co-worker or supervisor had to read your case notes, would he/she be able to understand and get a clear picture of what is going on with the participant?

63. In Summary Why is Good Case Noting Important? Provides a Picture Provides Documentation Provides Protection Keeps you focused on what you are working on and why