Case Management Notes Examples for Case Managers
Last updated:
Case managers document each client contact, referral and care coordination step, usually in PIE, SIRP or DAP format, plus service plans that set goals and responsibilities. Notes must show what was done, by whom and what follows. The examples below cover housing, benefits, crisis follow-up and a collateral call. WellNotes drafts each from a short summary.
You're coordinating between psychiatrists, social workers, housing agencies, and family members. Document every contact, referral, and follow-up without letting anything fall through the cracks.
Plans from $27/mo · Cancel anytime
Where Do Case Managers Lose Time on Documentation?
Documenting every phone call, coordination meeting, referral, and client contact across a caseload of 30-50+ clients
Tracking progress toward functional goals (housing, transportation, benefits access) that don't fit clinical note formats
Meeting strict Targeted Case Management (TCM) documentation standards for Medicaid billing, with monthly progress summaries, service activity logs, and payer-specific requirements
Spending more time documenting services than actually delivering them to clients who need support
Which Note Formats Do Case Managers Use, and Why?
Case management notes record actions more than therapy content: calls made, forms filed, appointments arranged and barriers removed.
PIE
Problem, Intervention, Evaluation tracks a need from identification to outcome, which matches how case managers work through barriers.
PIE Notes template and examplesSIRP
Situation, Intervention, Response, Plan suits field visits and crisis contacts where the situation changes quickly.
SIRP Notes template and examplesService or treatment plan
Goals, action steps, who is responsible and target dates, reviewed on the schedule your program requires.
Treatment Plan template and examplesAlso useful: SOAP Notes.
What Are the Documentation Requirements for Case Managers?
Case management documentation is often driven by the funding program, such as Medicaid targeted case management, a grant or a managed care contract.
Contact logs
Programs commonly require a note for every contact, including phone calls and collateral contacts, with date, duration, type of contact, purpose and outcome.
Link to the service plan
Each activity should connect to a goal in the service plan. Reviewers look for the thread from assessed need to plan to action.
Program-specific rules
Medicaid targeted case management and many grants define which activities are billable, the minimum contact frequency and the timelines for plan reviews. These vary by state and program.
Releases of information
Before sharing information with another agency, note the signed release on file and what was shared.
General information, not legal or billing advice. Requirements vary by state, payer and employer; check your licensing board, payer contracts and agency policy.
What Do Case Management Notes Look Like? 4 Examples
These invented examples use initials only. Each records the contact type and length, the actions taken, the client response and the next step with a date, and names the service plan goal where one applies.
Fictional PIE note, housing coordination
Invented example. Client "B.H.", 52, recently discharged from inpatient care.
Problem
Client staying with a cousin until the end of the month. No income since discharge. Missed primary care appointment last week due to transportation.
Intervention
Home visit, 60 minutes. Completed SSI application with client. Called the housing authority to confirm waitlist status. Scheduled Medicaid transportation for the rescheduled PCP visit. Release on file for the housing authority.
Evaluation
Application submitted. Waitlist position confirmed. Client agreed to keep a calendar for appointments. Follow up by phone in 3 days, home visit in 1 week. Service plan Goal 2 (stable housing) in progress.
Fictional DAP note, benefits recertification
Invented example. Client "C.V.", 38, SNAP recertification due in 10 days. Office visit, 40 minutes.
Data
Client brought two pay stubs and a utility bill but no proof of rent. Recertification notice arrived last week. Client asked what happens if the deadline is missed.
Assessment
Client is organized and motivated but anxious about losing benefits. The missing rent statement is the only barrier to a complete packet.
Plan
Client to request a rent statement from the landlord by Friday. Submit the packet online together at the Monday visit. Service plan Goal 1 (income and food security).
Fictional SIRP note, crisis follow-up call
Invented example. Client "K.J.", 24, seen in the emergency department 2 days ago and released home. Phone contact, 25 minutes.
Situation
Follow-up call within 48 hours of the emergency department visit. Client is staying at her mother's home.
Intervention
Reviewed the safety plan given at the emergency department, including warning signs and crisis line numbers, and checked that medications at home are secured. Confirmed the outpatient intake on Thursday at 10 am and arranged a ride.
Response
Client denied current intent or plan to harm herself, named two coping steps she used last night and agreed to call the crisis line if urges return. Mother confirmed medications are locked away.
Plan
Call again tomorrow afternoon. Notify the outpatient clinician of the visit (release on file). Home visit after the intake appointment.
Fictional DAP note, collateral call with a primary care office
Invented example. Client "W.A.", 60, blood pressure medication lapse. Phone contact with the clinic, 10 minutes, release on file.
Data
Clinic reported the refill request was denied pending an office visit. Client has been without his blood pressure medication for 3 days after missing last month's appointment.
Assessment
The medication gap is a health risk caused by a missed appointment, not a refusal. Client has no transportation on weekdays.
Plan
Clinic agreed to a 7-day bridge refill and an appointment next Tuesday. Call the client today with the details and book Medicaid transportation. Service plan Goal 3 (health access).
How Does WellNotes Work for Case Managers?
Log the Contact or Service
After a client meeting, phone call, or coordination contact, dictate what happened, services discussed, referrals made, client participation, and barriers identified.
Get a Structured Coordination Note
WellNotes organizes your documentation into a clear note that captures the service provided, client response, progress toward goals, and next steps for follow-up.
Review and Export
Review the note, then export it as a PDF or CSV or copy it into your records system, so your documentation tells the complete story of care coordination.
What Free Resources Help Case Managers?
Free note generators
Generate one note a day from brief, de-identified session details. No account needed.
Comparing tools? AutoNotes alternatives · Blueprint alternatives
I make 15-20 contacts a day between clients, providers, and agencies. Before WellNotes, half of them went undocumented because I just couldn't keep up. Now I dictate after every contact and nothing slips through.
Priya S.
CCM, Behavioral Health Case Management
How Much Does WellNotes Cost, and Where Are Notes Stored?
Starter
$27/mo
50 notes per month, all 15 formats
Professional
$38/mo
Unlimited notes and custom templates
- Your first subscription starts with a 3-day free trial (card on file); voice dictation unlocks when your paid plan starts.
- PDF and CSV export, or copy into any EHR.
- Saved notes stay in your own browser, not on our servers, and are cleared when you log out, so export them first.
Case Managers: Frequently Asked Questions
What should a case management note include?
Date, time and type of contact, who was involved, the purpose, actions taken, the client's response and the next step with a due date. Link the activity to the service plan goal it supports.
Do phone calls need a case note?
In most programs, yes. A brief note with the date, who you spoke with, the purpose and the outcome is typical. Your funding program may set the exact requirements.
Which note format is best for case managers?
PIE is popular because it follows a need from problem to outcome. SIRP works for field and crisis contacts, and DAP for quick routine check-ins. Many agencies set a standard format.
Can I use WellNotes for case notes?
Yes. WellNotes includes PIE, SIRP and DAP among its 15 formats. Enter initials rather than names, then copy or export the finished note into your agency system.