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Case Management Templates
Specialty Drug - New Member
- Office/Facility Contact and Authorization Request Details
- Location Where Medication Will Be Administered
- Past Medical and Surgical History
- Family History
- History of Current Diagnosis
- Previous Medication Trials
- Active Medications
- Social History
- Sequential Visits/Notes
- Note Date/Provider
- Specific Symptoms/Disease Activity
- Labs / Imaging / Vitals / PE / ROS - when applicable
- Provider Plan
- Treatment Changes
- Patient Story Summary
Specialty Drug - Ongoing Member
- Office/Facility Contact and Authorization Request Details
- Location Where Medication Will Be Administered
- Sequential Visits/Notes
- Note Date/Provider
- Specific Symptoms/Disease Activity
- Labs / Imaging / Vitals / PE / ROS - when applicable
- Provider Plan
- Treatment Changes
- Patient Story Summary
Pain Management - New Member
- Specific Auth Request Details (if any)
- Past Medical and Surgical History (PMSH)
- Current Medications
- Previously Tried Pain-Related Interventions
- Pain Management Clinical Documentation
- Chief Complaint or Reason for Visit
- History of Present Illness
- Pain Score Rating
- Physical Exam
- Vitals
- Labs
- Imaging
- Procedures
- Provider Plan
- Next Appointment
- Patient Story Summary
Pain Management - Ongoing Member
- Specific Auth Request Details (if any)
- Pain Management Clinical Documentation
- Chief Complaint or Reason for Visit
- History of Present Illness
- Pain Score Rating
- Physical Exam
- Vitals
- Labs
- Imaging
- Procedures
- Provider Plan
- Next Appointment
- Patient Story Summary
Psychiatry - New Member
- Specific Auth Request Details (if any)
- Start of Care & Level of Care (Initial and Current)
- Past Medical and Surgical History
- Past Psychiatric History
- Family Psychiatric History
- Social History
- Barriers to Stepdown
- Home Medications (Pre-Admission)
- Treatment Notes, in ascending order
- Note Date/Provider/Type of Note
- Specific Problems/Symptoms Now
- Current/Recent Substance Use
- MSE (Mental Status Exam)
- Psychiatric Rating Scales
- Medications
- Labs
- Vitals
- PE
- Imaging
- Procedures
- Assessment/Plan
- Stepdown Plan
- Discharge
- Patient Story Summary
Psychiatry - Ongoing Member
- Specific Auth Request Details (if any)
- Start of Care & Level of Care (Initial and Current)
- Barriers to Stepdown
- Treatment Notes, in ascending order
- Note Date/Provider/Type of Note
- Specific Problems/Symptoms Now
- Current/Recent Substance Use
- MSE (Mental Status Exam)
- Psychiatric Rating Scales
- Medications
- Labs
- Vitals
- PE
- Imaging
- Procedures
- Assessment/Plan
- Stepdown Plan
- Discharge
- Patient Story Summary
Acute/Chronic - New Member
- Specific Auth Request Details (if any)
- Medical History
- Surgical History
- Family History
- Social History
- Medications
- Allergies
- All visits, in ascending order:
- Note date & Provider Name
- Chief Complaint and Reason for Visit
- History of Present Illness
- Review of Systems
- Physical Exam
- Vital Signs
- Labs
- Imaging
- Assessment/Plan
- Next Appointment
- Patient Story Summary
Acute / Chronic - Ongoing Member
- Specific Auth Request Details (if any)
- All visits, in ascending order:
- Note date & Provider Name
- Chief Complaint and Reason for Visit
- History of Present Illness
- Review of Systems
- Physical Exam
- Vital Signs
- Labs
- Imaging
- Assessment/Plan
- Next Appointment
- Patient Story Summary
Utilization Review Templates
Outpatient Review
- Date & Provider Name for most recent note
- Assessment/Plan (requested service)
- DX (Diagnosis)
- Chief Complaint
- HPI (History of Present Illness)
- ROS (Review of Systems)
- PE (Physical Exam)
- PMSH (Past Medical and Surgical History)
- Family History
- Conservative Management / Prior Treatment
- Medications
- Labs
- Imaging
- Orders
- Other notes attached
- References
Admission Review
- Admission Date and Time
- Initial Level of Care
- Days of Care
- Reason for Admission
- Applicable codes for admission
- Primary Diagnosis
- Secondary Diagnosis
- Driving Diagnosis
- Other Conditions Being Treated
- Current Level of Care
- Bed-Type
- ED Course
- H&P
- Past Medical and Surgical History
- Vital Signs
- Labs
- Imaging
- Surgical Procedures
- Other Procedures
- Consulting Specialties
- Plan
- Discharge
Multi-Day Review
- Admission Date and Time
- Initial Level of Care
- Days of Care
- Reason for Admission + History of Presenting Illness
- Past Medical and Past Surgical History
- Home Medications
- Applicable codes for admission
- Primary Diagnosis
- Secondary Diagnosis
- Current Level of Care
- Admission
- Labs
- Vital Signs
- Physical Examination
- Review of Systems
- Assessment + Plan
- Driving Diagnosis
- Other Conditions Being Treated
- Clinical Course (including daily vitals, labs, imaging, and facility-administered medications)
- Discharge
- Status
- Plan
- Medications
- Summary
Pain Management
- Pain Diagnoses
- Other Diagnoses
- Pain Medications
- Other Medications
- Surgical history for pain conditions
- Procedure history for pain conditions
- Other pain-related treatments
- Plan
Rehabilitation
- Therapist Discipline (PT/OT/SLP)
- Initial Visit
- Visit Date
- Clinical Summary
- Provider Script
- Assessment Summary
- Diagnoses
- Rehab Potential
- Injury/Accident Context
- All Subsequent Visits
- Visit Number
- Visit Date
- Assessment and Diagnosis
- Subjective Summary including assessment from provider, HEP compliance, patient complaints and patient gains
- Objective findings
- Short-term goals
- Long-term goals
- Skilled interventions or modalities
- Barriers or limiting factors
- Plan for the next visit
Behavioral Health
- Initial and Current Level of Care
- Past Medical and Surgical History
- Past Psychiatric History
- Family Psychiatric History
- Social History
- Home Medications (Pre-Admission)
- Initial Intake Evaluation
- Collateral Information
- Initial Psychiatric Provider Assessment/Evaluation
- Treatment Notes, in ascending order
- Date/Time, Provider, Type of Note
- Daily Narrative
- Patient Participation in Therapy
- Medications
- Labs
- Vitals
- Diagnostics
- Procedures
- Other Events
- Discharge
- Anticipated Length of Stay / Anticipated Discharge Date
- Barriers to Discharge
- Discharge Disposition and Needs
- Discharge Status
- Discharge Summary
- Aftercare Plan
Discharge Summary
- Admission Date and Time
- Discharge Status
- Discharge Summary
- Discharge Plan
- Discharge Medications
NICU
- Delivery Information
- Maternal/Pregnancy History
- Date of NICU Admission
- Admission Details
- Clinical Summary
- All Operative/Procedure Reports
- Provider Progress Notes
- Date
- Clinical Summary
- Labs
- Diagnostic Testing
- Medications (changed / stopped / started)
- Estimated Length of Stay
- Anticipated Discharge Date / Disposition / Needs
- Discharge Summary
