Home Health & Hospice

What does clinical documentation show?

Homecare Insider, March 21, 2016

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:

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