• Just as crucial to the ability to provide nursing or professional services in the home, is the ability to justify what the patient’s/client’s needs are, what the nurse or other professional does in the home, and why it is done. Documenting the care provided is just as important as the quality of care provided. The attention to detail is necessary and the importance of accuracy and comprehensiveness is critical. General Documentation Issues Required by Law • The record must be accurate. Poor documentation can lead to errors in the care of the patient/client. All care requires a physician’s and/or non-physician practitioner’s order, which must be current, documented, and available for all staff providing care impacted by the order. • A statement made by a patient/client and/or family can be recorded in quotation marks to indicate the source of the information. In general, conclusions should be avoided, and the actual data recorded. • Initial and ongoing assessments and interventions must be documented in the record. The RN case manager should be notified of any change in patient’s/client’s condition. Staff should record who was notified of changes in the patient’s/client’s status, including times and dates. Any other follow-up care should then also be documented. • In the home care situation, it is important to document objective facts and direct observations. Basic Principles of Effective Documentation • Draw a single line through an error. Then date and sign the correction. • Never white-out, erase, or write over a previous entry, whether handwritten or computer generated. • Entries must be made in a timely manner, i.e., clinical notes must be completed the day care is provided and filed in the record within 14 business days or as required to comply with state regulations. • Avoid contradictions or inconsistencies in the chart. • Date when reports are received. Date and time orders when received. • Use standard abbreviations. • If additional information is remembered later, write it as an addendum titled “late entry” with date, signature, and title. • All documentation should be legible and include the date, time, signature, and title. • All entries should be written in ink. Documentation Tips • Use such words as: o Observation and assessment
