Florida Public Health Review

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Case management is a core HIV health service that focuses on service coordination—the seamless access to an array of integrated services. Integration aims to reduce barriers to medical care. In the busy HIV health services environment, inadequate documentation of case management activities limits the capacity of stakeholders to know what happens during care encounters. This study used theory and qualitative inquiry to uncover best practices that support optimal case management documentation. Two research questions guided the inquiry: What principles should arise in higher order cognitive functioning among case managers during client encounters? What characteristics of a system level approach to care encounter documentation reinforces case management critical thinking skills? The study settings included two, Northeast Florida, Ryan White funded organizations. Findings indicated that the confluence of intrapersonal, interpersonal, organizational, community, and policy factors support more rather than less robust case management documentation. A multi-tired approach to documentation of services rendered is no panacea. However, it offers a useful framework for defining stakeholders’ roles and expectations and monitoring the performance of activities. Disseminating these findings in the local Ryan White network and the public domain may trigger dialog and more research about the preservation and effective use of documentation skills.