Helping Hands Home Assistance
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Documentation 101
Keys to Effective Charting

Types of Information

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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.

Progress Notes
Nursing Notes Form
Elimination Form
Food Intake Form
Behavior Log
Incident Form

Common Rules of Documentation

  1. Document what you see, hear, feel, measure and count. Use description or tell it like it is. Give yourself credit…always document completed tasks.
  2. Document as soon as possible after giving care.
  3. Document completely and accurately.
  4. Document only your own information or observations. Other care givers need to document their observations, as well.
  5. 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.”
  6. 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.
  7. Include the date and time you wrote your entry.
  8. Write on every line…look for blank spaces.
  9. Use ink.
  10. Avoid altering the documentation or using white out.
  11. Write legibly, so that anyone can read it.
  12. Write clear sentences that get to the point.
  13. Use simple words.
  14. Avoid slang words like “drunk, loony, nasty, or mean.” And avoid swear words.
  15. Submit required paperwork timely!
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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.

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Progress Notes Checklist


Examples of Progress Notes


KanTime

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.


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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!