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Keys to Effective Charting
Types of Information
- Objective information - things that are observed using the senses, such as something you can see or smell.
- Subjective information - something you cannot directly observe, such as something a client tells you.
- Errors/Inaccurate information – do not use white out or “scribble” through. Use only a single “strike” through line and your initials in black ink.
- Incomplete information – not providing service dates and times, client signature, and checking completed tasks.
The Importance of Documentation
The client’s record is a legal document.
The documentation within the client’s record communicates important facts, findings, and observations about the client’s physical or mental status.
Proper documentation reflects the quality of care given to clients and shows that HHHA is following the rules of home care.
“If it is not documented, it did not happen.”
Examples of forms used for care
There are many forms and logs that may be part of a client record. Depending on your client’s situation, you may already be using several of the forms listed here. Your supervisor will talk with you one-on-one if you are required to use any forms other than Progress Notes.
Nursing Notes Form
Food Intake Form
Common Rules of Documentation
- Document what you see, hear, feel, measure and count. Use description or tell it like it is. Give yourself credit…always document completed tasks.
- Document as soon as possible after giving care.
- Document completely and accurately.
- Document only your own information or observations. Other care givers need to document their observations, as well.
- The person documenting needs to write objective and subjective information.
— However, be careful to avoid documenting personal opinions, such as “The client is cranky today.”
— Find a way to describe subjective opinions with objective information, like: Client said “I’m in a bad mood today.”
- Make sure you are writing in the correct client’s record and their name is on the page. You are never permitted to strike out client names and write in another. Most forms are client specific.
- Include the date and time you wrote your entry.
- Write on every line…look for blank spaces.
- Use ink.
- Avoid altering the documentation or using white out.
- Write legibly, so that anyone can read it.
- Write clear sentences that get to the point.
- Use simple words.
- Avoid slang words like “drunk, loony, nasty, or mean.” And avoid swear words.
- Submit required paperwork timely!
Types of Documentation Required at the Home of Clients
Log in significant changes.
The documentation showing something has changed in the client’s behavior, their mental status, or their physical health.
Incident or Accident Reports.
— The documentation about incidents or accidents.
— Fill out incident report with specific explanation of what happened, how you and client responded, how you followed up.
— If accident happens and medical assistance is needed, call 9-1-1 immediately, and see about client.
Report incidents to office immediately!
Daily Progress Notes
Why are Progress Notes so important?
Your progress notes are your paycheck!
They also document completed tasks.
Progress Notes Checklist
- Always sign and write your Team Member# on top of every progress note.
- You must write your Start and End times for every scheduled shift.
- Please mark all tasks that you completed during your shift. Use the Notes section to write in any additional tasks.
- Always have the client sign for each day of service at the end of each shift, NOT before Start and End times, and completed of tasks are filled in.
- Be sure to check client plan of care.
- If Personal Care is required – make sure that you are providing this service and marking the progress note – Cleaning the bathroom is counted as Personal Care or Attendant Care.
- If your client receives Homemaking – make sure that you are marking the progress note in the Homemaking section.
- If a client has AM and PM shifts, put them on separate progress notes. You should have an AM and a PM progress note for these clients.
- Do not use notebook paper. If you are asked to go to a client’s home, let us know in advance if you do not have progress notes.
- Do not put separate weeks of service on the same progress note. Use one progress note for each week of service.
- Each week progress notes are rejected because of errors and incomplete information.
Examples of Progress Notes
All Caregivers must clock-in and –out of KanTime for each shift (877-845-4442) in order for their payroll to be processed.
If you excessively do not use KanTime you will be scheduled for further training
— If problems not attributable to KanTime persist after re-training, disciplinary action will be taken.
— In the rare instance that KanTime is malfunctioning, or any other problem occurs with clocking in or out, you must call CSD immediately to report the problem and provide work start/end time.
Progress Notes must be received no later than 5:00 pm every Tuesday. If Progress Notes are received after the mandatory deadline, your payroll will be processed and ready for distribution the following Payday. NO Exceptions!
Progress Notes/Daily Activities Logs cannot be faxed. Original documents are required for compliance regulations.
Submitting Progress Notes
Progress Notes must be signed by Client or Client Representative only. Under NO circumstance is a Caregiver permitted to sign Progress Notes for any Client, which would constitute falsification of records. Falsification of progress notes will result in immediate termination of employment.
Your accuracy and commitment makes the difference!
Thanks for doing a great job!