Documentation for home health care

Documentation for home health care

Avoiding malpractice is more than avoiding a lawsuit, it is avoiding the litigation process altogether. Proper documentation is arguably the most important element in avoiding malpractice and litigation for nurses. There are many reasons why nurses spend much of their time charting. However, when it comes to malpractice and the litigation process, documentation may be the only evidence a nurse has to defend his or her position.

By the time a lawsuit is filed, chances are the nurses will not remember the particular patient involved, especially if they only cared for the patient for one or two shifts. Even if the nurses do remember the patient, it is their documentation that will be reviewed, presented and relied on, not their memory.

All nurses have been taught, “If it’s not written, it’s not done!” But, what exactly does that mean? Whether you are a student nurse or have been in nursing for thirty years, this question may be difficult to answer.

Over the years, documentation has changed a great deal. But, the rationale behind why documentation is important remains the same. Whether you are documenting with a narrative style, using flow sheets or charting by exception, the purpose of documentation is to memorialize what occurred while you took care of your patient and to capture relevant information about the patient’s condition and medical history. The more accurately your documentation depicts what actually happened during the time you took care of your patient, the more likely you are to avoid becoming involved in litigation for malpractice.

Regardless of the type or style of charting a nurse uses, it is important for documentation to be legible, logical, and complete. Not only to prove what occurred, but to also show what did not occur. For example, if a patient is admitted to a facility with both arms in tact, and claims to have left the facility with a broken arm, the first thing the patient’s attorneys and their experts are going to do is review the medical records. They will try to determine from the records when and how this patient’s arm could have been broken.

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19 thoughts on “Documentation for home health care

  1. i agree with the description above. documentation must be properly maintained and recorded in order for us to monitor and regulate whatever health care treatment or program is given to the patient

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  3. Here in California the embezzelment is a out of control! Make sure who you hire to take care of your loved ones. Most of these so-called nurses are not back grounded because most come from other countries. So when they are hired in america to watch seniors, they look for every chance to steal PIN numbers bank information, obtain power of attorny. Just be very wise about whom you hire to watch your loved ones. thats my message here.

  4. It’s difficult to find knowledgeable people on this topic, but you sound like you know what you’re talking about! Thanks

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  9. It is a very good information, but whoever was doing the transcript obviously is not paying attention!!!

    6:23 "incident report shit also be completed"

    To: Paloma Home Health I suggest that you check the transcript!!

  10. Agencies want 6 visits a day and say they are paying for an 8 hour day. You are supposed to write everything and drive to the office to get supplies and call the doctor and the pharmacy and oh and drive to each patient + all the documentation; transfers, incident report, infection control (we don't get paid for our time completing the forms) Oh and labs we don't get paid to collect the blood, find a lab and drop the blood off.  Mileage No not paid for that either. Tolls/parking: no. Oh and also even though we see the patient only once a week we are responsible if they fall or do not take their meds properly or get sick and go to the hospital. Don't forget we should read their charts so we know when every entity saw the patient and what they assessed. Try doing this and do it accurately (remember the rules are always changing and are interpreted differently from agency to agency) Is this really about patient care? I am starting to lose perspective.
    People love to make the videos and give seminars and make it sound so simple and doable. I say often: walk in my shoes and now give that seminar. It will sound different. Your/my documentation is used for QA; making sure you addresses each topic but no one is reading with a real patient in their vision and no one seems to care. Just get the note in and say they are homebound and by all means recertify them at all costs; they will even pay you a bonus if you will somehow find a way to recertify them ( this is easy money …so say the agency billing, admin. owners say). My vision is cloudy. Are you honest? Do you really know what homecare entails?  If you do, then yours is cloudy too.
    I am in homecare because I love the1:1 aspect but I know I am being abused (with unrealistic rules, expectations and goals and a lot of guilt when anything goes wrong)and misused. Try talking about infection control and home care.  Um Hum you can out line it very nicely and tell me what to do; have you done it? I have been out with the best who acclaim themselves in home infection control experts. Not one has ever  and I said ever been able to follow the entire protocol we are expected to follow. Not one. In the next You tube video or seminar will you please be a for real nurse advocate and tell it the way it really is….all of it. I do in home visits and have not had a pay raise in 15 years, Go chew that and give me one more rule and expectation.

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