HEALTHCARE CASE MANAGEMENT CHECKLIST TEMPLATE

Created by ChecklistGuro (https://checklistguro.com)


--- INTAKE & ASSESSMENT ---
[ ] Client Full Name
[ ] Date of Intake
[ ] Presenting Problem/Reason for Referral
[ ] Age
[ ] Primary Language (English, Spanish, Other)
[ ] Client Address
[ ] Referral Documents (if applicable)
[ ] Emergency Contact Information

--- CARE PLAN DEVELOPMENT ---
[ ] Client Strengths & Resources
[ ] Client Goals (Short-Term)
[ ] Client Goals (Long-Term)
[ ] Goal Completion Timeline (Weeks)
[ ] Primary Focus Area (Medical, Social, Financial, Behavioral Health)
[ ] Services Required (Medical Appointments, Medication Management, Therapy, Financial Assistance, Housing Support, Transportation)
[ ] Care Plan Review Date

--- SERVICE COORDINATION ---
[ ] Referral Source (Hospital, Physician, Social Services, Family, Self-Referral, Other)
[ ] Services Scheduled (Medical Appointments, Therapy Sessions, Transportation, Financial Assistance, Legal Aid, Housing Support, Other)
[ ] Appointment Date
[ ] Appointment Time
[ ] Service Location
[ ] Provider Name
[ ] Coordination Notes

--- PROGRESS MONITORING & EVALUATION ---
[ ] Progress Monitoring Date
[ ] Goal Progress (Scale of 1-10)
[ ] Observed Progress & Challenges
[ ] Overall Assessment (Improving, Stable, Declining) (Improving, Stable, Declining)
[ ] Areas Requiring Adjustment (Medical, Social, Financial, Emotional, Housing)
[ ] Plan Modifications & Next Steps

--- COMMUNICATION & COLLABORATION ---
[ ] Last Communication Date with Client
[ ] Communication Method (Phone, Email, In-Person, Video Conference)
[ ] Summary of Communication & Key Discussion Points
[ ] Stakeholders Involved in Communication (Client, Family Member, Physician, Social Worker, Insurance Provider)
[ ] Next Scheduled Communication Date

--- DOCUMENTATION & RECORD KEEPING ---
[ ] Date of Record Creation
[ ] Summary of Initial Assessment
[ ] Progress Notes - Date Specific
[ ] Care Plan Updates (No Change, Minor Adjustment, Major Revision)
[ ] Supporting Documentation (e.g., Medical Records, Reports)
[ ] Communication Log (Dates, Parties, Summary)
[ ] Case Manager Signature

--- CRISIS INTERVENTION & SUPPORT ---
[ ] Crisis Level (Severity) (Low, Moderate, High, Imminent Danger)
[ ] Description of Crisis Event
[ ] Date of Crisis Event
[ ] Time of Crisis Event
[ ] Immediate Actions Taken (Contacted Emergency Services (911), Provided Emotional Support, Ensured Safety of Client & Others, Contacted Family/Designated Support, Other)
[ ] Details of Actions & Client Response
[ ] Client's Distress Level (1-10)
[ ] Supporting Documentation (e.g., notes, photos)

--- DISCHARGE PLANNING & TRANSITION ---
[ ] Planned Discharge Date
[ ] Reasons for Discharge
[ ] Post-Discharge Residence
[ ] Discharge Destination (e.g., Home, Assisted Living, Rehab) (Home, Assisted Living, Rehabilitation Facility, Hospital, Other)
[ ] Services Required Post-Discharge (Home Health, Medical Transportation, Meal Delivery, Social Worker Follow-Up, Financial Assistance, None)
[ ] Contact Information for Post-Discharge Support (Family/Friends/Community Resources)
[ ] Discharge Instructions Document

--- REGULATORY COMPLIANCE ---
[ ] HIPAA Compliance Status (Compliant, Partially Compliant, Non-Compliant, N/A)
[ ] Last HIPAA Training Completion Date
[ ] State Reporting Requirements (Required, Not Required, N/A)
[ ] Summary of Regulatory Updates Reviewed
[ ] Mandated Reporting Obligations (Yes, No, N/A)
[ ] Supporting Documentation (e.g., policy updates)

--- FINANCIAL MANAGEMENT ---
[ ] Client's Annual Income
[ ] Primary Funding Source (Medicare, Medicaid, Private Insurance, Self-Pay, Other)
[ ] Insurance Coverage Details (Policy Number, Effective Dates)
[ ] Insurance Policy Renewal Date
[ ] Financial Assistance Programs Applied For (SNAP, TANF, Section 8, None)
[ ] Outstanding Medical Bills
[ ] Notes on Financial Resources & Challenges

--- END OF TEMPLATE ---
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