Home Health & Hospice

Insider’s scoop | Know your protocols

Homecare Insider, March 21, 2016

Editor’s note: This week’s Insider’s scoop is from Clinical Documentation Strategies for Home Health. This comprehensive resource covers everything homecare providers need to know regarding documentation best practices, including education for staff training, guidance for implementing accurate patient assessment documentation, tips to minimize legal risks, steps to develop foolproof auditing and documentation systems, and assistance with quality assurance and performance improvement (QAPI) management. Click here for more information.

When nurse experts are asked to review a medical record in preparation for a legal case, they rely heavily on the clinical record to determine the following: 

  • Did the healthcare provider meet the policies and protocols of the organization at the time of the care? 
  • More importantly, did the healthcare provider meet the standards of nursing practice at the time of the care?

It is therefore the responsibility of the nursing management team and the nursing staff to follow the established policies of the organization, and to ensure that this compliance is demonstrated in the documentation system for that organization.

Organizational policies, protocols, and practices will always be called into review when there is an allegation of substandard patient care. Nursing practice will be held to national and local professional nursing standards, which are available through the ANA and through specialty nursing associations. If you derive your policies and procedures from these, your organization will be better able to justify that the care that was delivered met established professional standards.