o Teaching and instruction o Performance of skilled procedures o Specific observations rather than general • Use complete and accurate documentation, and reflect the care actually given at each visit. • Be as brief and concise as possible. • Be sure documented care reflects the patient’s/client’s diagnosis and plan of care (orders). • Write clinical notes so they can stand alone. • Elaborate on factors effecting the lack of progress. • Always document phone conversations with the patient/client, physician and/or non-physician practitioner, or home care providers. • Any instructions to the patient/client to make an appointment or follow-up with the physician and/or non-physician practitioner should be noted. Summary The importance of documentation in the medical record relates to the fact that this record is: • The only written source for reference and communication among members of the home care team. • The only text that supports insurance coverage and/or denial. • The only evidence of the basis on which patient/client care decisions were made. • The only legal record. • The primary foundation for the evaluation of the care provided. • The objective source for the Agency’s licensing, accreditation, and state surveyor review. Documentation is the key! The clinician needs to “paint a picture” for anyone who is reading the record. Please note approved abbreviations for documentation in following policy. Online Bookmark Title of Policy Management of Information (IM) Interfacing Standardized Information
