What makes home health documentation unique? The physician is the pivotal person in the charting. Home health care documentation has unique problems because of the need for different health care workers to access the medical record.
What should be included in patient documentation?
- The most current information.
- Clinically pertinent information.
- Rationale for decisions.
- Informed Consent discussions or the patient’s refusal of care.
- Discharge instructions.
- Follow-up plans.
- Patient complaints and response.
- Clinically pertinent telephone calls.
What are three examples of poor documentation practices in patient records?
- Sloppy or illegible handwriting.
- Failure to date, time, and sign a medical entry.
- Lack of documentation for omitted medications and/or treatments.
- Incomplete or missing documentation.
- Adding entries later on.
- Documenting subjective data.
- Not questioning incomprehensible orders.
How can you improve documentation skills in healthcare?
- Define professional standards.
- Expand education.
- Create peer-to-peer support systems.
- Review information.
- Allow patients greater access to EHRs.