Q&A: Cardiac case management documentation
by Melissa Varnavas
I was reading through an ACDIS sister e-newsletter Case Management Weekly and came across the Q&A below. I thought you might enjoy knowing how clinicians, regardless of their job description really are concerned about following the rules regarding clinical documentation. This particular question comes from a North Carolina case management professional who works on the cardiac unit. Essentially, she wants to know what piece of the documentation pie she specifically needs to own and what the regulations are that govern the requirements.
As CDI professionals, you may come across this frequently. How do you know whose job it is to document which aspect of the medical record especially as various roles—from case management to utilization review—start to overlap? As you can see from the question sent by Angie Rich, BSN, RN, CCM, and the answer by Karen Zander, RN, MS, CMAC, FAAN, complete documentation continues to be the best policy regardless of role or job description.
Q: I am a case manager on a cardiac step-down unit. Our work focuses primarily on specific disease management and patient contact/education and nurse mentoring/chart reviewing, patient rounding, etc. We are very clinically focused. We don’t do utilization review (UR) or discharge planning. We face the issue of case manager documentation. Legally, what must we document?
A: In this model, not doing utilization review allows the case manager to really focus on clinical progressions, which should be the focus of his or her documentation. The case manager should document how sick the patient is, and how the patient is progressing clinically each day. There’s no legal requirement for the case manager in this position to document, but there is a professional requirement to document the clinical progression as well as what the case managers taught the patient prior to discharge and how the patient responded. Every time they see, touch, or talk to a patient, the case managers should document it.