Case Management Progress Notes: Example & Template

What Are Case Management Notes?

Case management notes document the work of connecting a client with the services they need: assessing needs, building and revising a care plan, making referrals and linking the client to other programs, contacting other agencies, and following up to see whether services actually started. This page covers what each note should contain, how a case management note differs from a therapy note, what Medicaid case records must show, and why billing for targeted case management depends on your payer and state. It includes a filled-in example, a brief follow-up example and a downloadable template.

Case managers, care coordinators, social workers and nurses write these notes in community mental health centers, substance use programs, hospitals and social service agencies. In many settings the same person also provides counseling. When that happens the two services need separate notes, because payers define them as different services with different content and billing rules (see the community mental health documentation guide).

A therapist's occasional call to a school or a psychiatrist is a collateral contact, documented in a collateral contact note as part of therapy. Case management is different: coordinating access to services is the service itself.

A good case management note answers four questions for whoever picks up the case next. What does the client need? What was done about it today? What happened as a result? Who is doing what next, and by when?

Case Management Note vs. Therapy Note

	Case management note	Therapy progress note
Purpose	Help the client reach services such as housing, benefits, medical care, transportation or treatment programs	Treat symptoms and improve functioning through psychotherapy
Typical content	Needs, contacts made, referrals, appointments arranged, outcomes, barriers, follow-up tasks	Symptoms, interventions, the client's response, progress on clinical goals
Who is involved	Often other agencies and providers, with or without the client present	Usually the client, plus family or partner in conjoint work
Plan section	Tasks with a named owner and a due date	Next interventions, homework, session focus
Goals it reports against	The care plan or service plan	The treatment plan
Billing	Case management codes and units defined by the state Medicaid plan, a managed care contract or a funder	Psychotherapy CPT codes

The DAP format suits case management because its single Data section can hold both what the client said and what you did. The components below work equally well in DAP, SOAP or a narrative note.

When You Need It

• After any contact with the client about their needs, services or care plan, whether in person, by phone or by video
• After a call, email or meeting with another agency or provider on the client's behalf
• When you make a referral, book an appointment, or send an application
• When you follow up on whether a referral was received, an appointment kept or a benefit approved
• When you complete or update a needs assessment or the care plan
• When a client declines a service you offered
• When you coordinate with another case manager who serves the same client
• When you try to reach someone and cannot: an unsuccessful attempt still gets a short note with its purpose and next step

The Four Kinds of Case Management Activity

Federal Medicaid rules (42 CFR § 440.169) describe case management as services that help eligible people "in gaining access to needed medical, social, educational, and other services," and divide the work into four activities. The same four are a useful frame for case management notes in programs that are not Medicaid-funded.

• Assessment and reassessment of needs. Learning the client's history and current needs, including from family members, providers or teachers when that adds something. The note records what you learned and from whom.
• Developing and revising the care plan. Setting goals and actions with the client taking an active part. The note records the client's input and what changed in the plan.
• Referral and related activities. Linking the client with providers and programs: sending referrals, booking appointments, helping with applications. The note records who was contacted, what was arranged, and what is still pending.
• Monitoring and follow-up. Confirming that the planned services are happening, that they are enough, and whether the client's situation has changed, then adjusting the plan. The federal rule requires monitoring at least once a year; states set how often it actually has to happen. The note records what you checked and what you changed.

Naming the activity in each note, even in a word, makes it easy for a reviewer to see that the contact was case management and not something else.

Key Components

Contact details and time

Date, start and stop time of each activity, method, location, who took part, and whether the client was present. Record actual minutes and let your billing rule convert them into units.

Purpose and care-plan link

Which need the contact addressed, and which care-plan goal or objective it serves. A contact that connects to no part of the care plan is either a new need, which means the plan should be updated, or it is not case management.

Who was contacted, and on what basis

The name or role and agency of each person contacted, and the consent basis for the contact: a release on file (its date, who it names and what it covers) or the other legal basis you relied on. HIPAA's definition of treatment in 45 CFR § 164.501 includes a provider coordinating care with a third party, but state law, agency policy and, for substance use disorder program records, 42 CFR Part 2 can be stricter. Housing programs, employers, schools and courts are the contacts most likely to need a signed release. When in doubt, use the release of information process before you call.

What was done and what was learned

The actions you took, the actions the client took, and the information you received, kept within the scope of consent. Be specific: "faxed the referral to the clinic at 2:10 pm and confirmed receipt with the intake coordinator" says far more than "referred to clinic."

The client's response and choices

The client's view in their own words, what they accepted, and what they declined. Federal Medicaid rules list whether the client declined services in the care plan among the elements a case record must show, and they bar states from making case management a condition of other Medicaid services or the reverse. The record should read as the client's choices.

Outcome and barriers

The result of each action, what is still pending, and any barriers: missing documents, eligibility, transportation, cost, wait lists, language, disability access. Barriers are also where social determinants of health show up in the record. The ICD-10-CM Official Guidelines allow social determinants codes (categories Z55 to Z65) to be assigned from notes written by case managers, nurses, social workers or community health workers, as long as those notes are part of the official record. A line such as "staying at the shelter since 10/02" supports a code from Z59.0- (homelessness): Z59.01 for sheltered homelessness, as in the example below, Z59.02 for unsheltered homelessness, or Z59.00 when the record does not say which. Other barriers have codes of their own, such as Z59.41 (food insecurity) and Z59.82 (transportation insecurity).

Coordination with other case managers

Clients often have more than one case manager: one at the shelter, the hospital, probation or the health plan. Record who they are, what each is doing, and how you are avoiding duplicate work. Federal rules list the need for coordination with other case managers, and the occasions when it happened, among the required case record elements.

Follow-up plan

Each next step with the person responsible and a due date, the date and method of the next contact, and when the care plan is next due for review.

Safety observations

Case managers often see clients where they live. Record anything you observe that bears on safety or health, following your agency's protocol, and who you told and when. If you are not trained to assess risk clinically, document what you saw and heard and the handoff to a clinician.

What Medicaid Case Records Must Show

If you provide Medicaid case management, federal regulation (42 CFR § 441.18(a)(7)) requires states to have providers keep case records that show, for every client:

• the client's name
• the dates of service
• who provided the service, and for which agency where that applies
• what was provided (its nature, content and units) and whether care-plan goals have been met
• whether the client declined any services in the care plan
• the need for coordination with other case managers, and when it happened
• a timeline for obtaining the services the client needs
• a timeline for re-evaluating the care plan

States add their own requirements on top of this list, such as signature and timeliness rules, required forms and who may provide the service, so treat it as the floor rather than the whole standard. The NASW Standards for Social Work Case Management (2013) also give record keeping a standard of its own, asking social work case managers to document case management activity promptly in the client record.

Billing for Targeted Case Management Varies by Payer and State

Targeted case management (TCM) is a Medicaid state plan option under section 1915(g) of the Social Security Act. Each state decides whether to cover it, and its state plan defines:

• the target groups served (for example, people with a chronic mental illness or a developmental disability) and the geographic area
• the case management services included and the types of monitoring
• how often assessments and monitoring take place
• the qualifications case management providers must have
• how providers are paid, which can differ between subgroups

So a note that fully supports a claim in one state may fall short in another. The points that vary most, and that your documentation should match:

• Codes and units. HCPCS Level II includes codes for this work, among them T1016 for case management and T1017 for targeted case management, each counted in 15-minute units; T2022 and T2023, which cover a month; and H0006 for case management within alcohol and drug services. Your state decides which codes its Medicaid program accepts, which modifiers apply, and how minutes round into units. CMS's HCPCS file marks all five as not payable by Medicare.
• Contacts without the client. Federal rules let case management include contacts with people other than the client when the contact relates directly to the client's needs and care: a call to a landlord, a prescriber's office or a family member, for example. Whether those contacts are billable, and on what terms, is set by the state.
• What is not case management. Federal rules exclude the direct delivery of the underlying service the client was referred to, and the regulation's examples include providing transportation. Arranging a ride is case management; driving the client is not. Document the arranging.
• Managed care plans and other funders. Medicaid managed care plans, county programs and grant funders write their own documentation and unit rules into contracts, and commercial plans vary. Check each one you bill.
• An acronym to watch. In Medicare billing, TCM usually means transitional care management, a service after discharge from a hospital or facility that is billed by physicians and certain non-physician practitioners. It is a different service from Medicaid targeted case management.

Filled-In Case Management Note Example

The examples below are fictional. A case manager at a community mental health agency provides Medicaid targeted case management to an adult staying in a shelter. The state is fictional too: it adds up the day's case management minutes and counts them in 15-minute units, with 8 to 22 minutes as 1 unit, 23 to 37 as 2, 38 to 52 as 3 and 53 to 67 as 4. Real states set their own rules, so check yours.

Brief follow-up contact

Short contacts get short notes. They still need the time, the care-plan link, the outcome and the next step.

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How to Write It Step by Step

Step 1: Start from the care plan. Before the contact, check which goal or objective it serves and what was left pending last time.

Step 2: Confirm the consent basis for every outside contact. Look at the release on file: who it names, what it covers, when it expires. If it does not cover the contact, get a new release or limit what you share.

Step 3: Log time as you go. Write start and stop times for each activity and note whether the client was present. Do not round in the narrative.

Step 4: Write what you did, not that you "assisted." Name the call, the referral, the form and the person. "Assisted with housing" could mean anything.

Step 5: Record the outcome and what is still open. Every action should end with a result: done, pending, refused, or failed and why.

Step 6: Capture the client's choices in their own words. Include the services they declined and the reasons they gave.

Step 7: End with owners and dates. Every open item gets a name (client, case manager or another agency) and a due date.

Step 8: Update the care plan when the need changes. A new need, a goal met or a service ended belongs in the plan, not only in the note. When a client moves to another program, a treatment summary for transfer of care or a referral letter carries the history forward.

Common Mistakes

1. Vague verbs. "Assisted client with housing" hides the work. A reviewer cannot tell whether a referral was made, by whom, or with what result.

2. Therapy content in a case management note, or the reverse. If you spent twenty minutes of a home visit working through grief, that part was not case management. Billing one service while describing another is a compliance problem.

3. No link to the care plan. A contact that never mentions a goal or objective looks like activity without purpose, even when it was essential.

4. Open tasks with no owner or date. "Will follow up" is not a plan. Say who will follow up, about what, and when.

5. Documenting the ride instead of the linkage. Under federal Medicaid rules, providing transportation is not case management. Arranging it, and checking that it happened, is.

6. Leaving out declined services and preferences. A record that shows only what was accepted makes the client's choices invisible and leaves gaps a reviewer will notice.

7. No consent basis for outside contacts. Every contact with another agency should show the release or other legal basis it relied on. For substance use disorder program records, also check the 42 CFR Part 2 rules.

8. Padded time or units. Minutes in the note must match the clock. Travel, time on hold and documentation time count only if your state's rules say they do.