Tip of the week
Rehab Regs, September 19, 2008
Documenting events, occurrences, interactions, and outcomes in a medical record serves many purposes, including regulatory, financial, and administrative.
The medical record is not solely a dated history of the patient’s care. Each entry should have meaningful content that enables subsequent caregivers to understand what care has been provided, understand the reasons for the care decisions made, know that the required care was provided, and evaluate the significance of late patient outcomes.
Frequently omitted entries include:
• Patient and family education
• Conversations with patients and families in person or over the telephone
• Cues or redirection given to a patient
• Safety-related instructions
• Conversations with physicians or other practitioners in person or over the phone
• One-on-one time or visits with patients
• Family requests and responses to those requests.
This tip is from HCPro’s Pocket Guide to Therapy Documentation.
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