Patient Evaluation vs. Case Management
Proper case management has its roots in the patient’s clinical presentation and the doctor’s training and expertise. Doctors have a fiduciary responsibility to evaluate patients to determine the entire clinical picture. The patient evaluation process is quite linear. Here is an example of the flow of an initial visit:
Once the doctor has completed these initial visit procedures, they should present the patient with a verbal report of the findings. From there, the provider is simply executing the treatment plan, during the subsequent visits of the episode of care, laid out based on these initial visit findings.
The case management portion of the equation now takes place throughout the subsequent visits of the episode of care. The visit-to-visit evaluation, aka case management, is the process that directs the doctor in ways that the baseline treatment plan may need to be altered. It should never be assumed that once the treatment plan is set, treatment will automatically continue in that fashion. Additional case management is always recommended.
Initial evaluation without ongoing case management is dangerous and unwise. “Doctor thinking” must take place on a visit-to-visit basis to determine the need for ongoing care. When documented in the patient’s record, this is proof that the provider is considering the actual patient’s presentation by the visit to verify that the treatment plan is working (or not) and to follow through with next steps.
This is no time to “set it and forget it!” Constant and continuing assessment is the name of the game for good case management.
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