The Importance of Documentation

jose alejandro

“If it is not documented, then it is not done.” These words continue to be a powerful reminder of the importance of thorough documentation. This is especially true in our role as professional case managers in facilitating and coordinating care across the continuum. Thorough documentation is also essential to verify that we followed regulations associated with discharge planning.

For example, in California regulations require thorough documentation when discharging individuals who are homeless. Failure to provide substantive documentation to this requirement could result in administrative penalties up to $125,000 by licensing authorities. Other enforcement and legal ramifications for both the organization and potentially the licensed nurse or social worker involved in the discharge plan could also result (California Hospital Association, 2018). The Centers for Medicare & Medicaid Services also has extensive regulations specific to discharge planning, patient preference and patient rights (CMS, 2019).

Homelessness is a complex issue and is not just limited to the United States. Research by Oh, J. & Oh, S. (2017) notes that case managers in Korea face many of the same challenges as their U.S. colleagues in finding safe discharge options for patients with complex medical and mental health needs. Stirring was their reflection that case managers can many times “become the enemy” when proposing discharge options (Oh, J. & Oh, S., 2017).

This issue of CMSA Today explores how we can continually improve case management practice through ongoing education, critical thinking, reflective practice and deployment of evidence-based practice. Collaborative practice is key to developing safe discharge plans to our most vulnerable patients. In addition, we have a critical role specific to political advocacy and building awareness in meeting the needs of the individuals we care for.

The Case Management Society of America website also has a number of resources that are available to you. For example, our Educational Resource Library contains substantial continuing education to support your professional development. Lifelong learning supports competent practice and keeps us current with evidence-based practice.


California Hospital Association. (2018). Discharge planning for homeless patients. Retrieved from:

Centers for Medicare & Medicaid Services. (2019). CMS’ discharge planning rule supports interoperability and patient preferences. Retrieved from:

Oh, J. & Oh, S. (2017). Nurse case managers’ experiences on case management for long-term hospitalization in Korea. Asian Nursing Research. 11(4), pp 283-9.

Jose Alejandro, PhD, RN-BC, MBA, CCM, FACHE, FAAN

President, CMSA 2018-2020

Dr. Alejandro is the Director of Case Management at UC Irvine Health, Orange County’s only Level 1 Trauma and Burn Center.


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