August 2010
Department 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

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.)
Case Narrative
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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

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
Case Narrative
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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
MW Monthly
Telephone or
Face-to-face
GR Monthly
Telephone or
Written
Correspondence
MW Quarterly
Face-to-face
Activity
Program
Assess Client
Status
ADA (Telephone), ALE (Face-toface)
Confirm
Caregiver
Eligibility
HCE*
Care Plan Review
ALE, ADA
GR Semi-annual
Face-to-face
Care Plan Review
ADI, CCE, HCE (LSP and
OAA Case Managed Clients)
Annually
Face-to-face
Assessment/
Reassessment
ADA, ALE, ADI, CCE, HCE (LSP and
OAA case managed clients)
GR 14 Business*
Day Follow-up
Telephone or
Face-to-face
Service Initiation
or Referral
ADI, CCE, HCE (LSP and OAA Case
Managed Clients)
* This can be done by a case aide with CM
supervision .
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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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7.
8.
Client’s hygiene and grooming
Client’s dress
Client’s facial expression/affect
Client’s mannerisms
Client’s response to others or to activities
Client’s interaction with the case manager or
service worker
Caregiver changes
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
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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
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Caregiver related
Emotional
Environmental
Financial
Physical
Social
Service related
Mental
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Example:
 Services
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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 attitude
c. Service worker compliance
d. Service worker dependability
e. 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 care
4) Arranging for service delivery
5) Following up and monitoring service provision
and quality of services
6) Recording case management activities in the
recipient’s record
7) Recipient visitation
8) Telephone, travel time and recording of progress
notes associated with billable activities
9) 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)
•MW cannot bill after date of death or after nursing
home/hospital entry. GR has 60 days after date of death.
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Reimbursable Activities
Reimbursable Activities
(not specifically addressed)
1) Assistance with implementing plans of
care
 Contact with persons to monitor service
receipt and satisfaction
2) Oversight and supervision of provider
training activities
 Documentation of activities in case record
3) Paraprofessional tasks intended to
maximize productivity of case managers
 Telephone and travel time associated with
billable case aide activities
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*
* ADI, CCE, HCE, and LSP and OAA case management only
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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.
2.
3.
Summers, N. (2001). Fundamentals of Case
Management Practice Belmont, CA:
Wadsworth/Thomson Learning.
Medicaid Waiver Handbooks
DOEA Programs and Services Handbook
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