Recording-2025-03-05T19:34:48.502Z

Documentation Standards

• Importance of Documentation

  • Documentation is crucial for patient care reimbursement from insurance companies.

  • Accurate notes are critical, especially if an incident occurs involving a patient.

  • Review of notes may occur if issues arise, highlighting the need for thoroughness in documentation.

Time Format for Documentation

• Use of the 24-Hour Clock

  • Always document using military time (00:00 to 23:59).

    • For example, use 14:00 instead of 2 PM, 16:00 instead of 4 PM.

  • New day begins at 00:00 (midnight) and ends at 23:59.

Methods of Documentation

• Types of Information to Document

  • Documentation should include both subjective and objective data.

    • Subjective Information: What the patient reports (e.g., "I have chest pain").

      • Use quotations around subjective data, e.g., Patient states, "I have chest pain."

    • Objective Information: Observations and measurable data.

Timeliness of Documentation

• Documenting in Real-Time

  • Always document when care is provided, not at the end of the day.

    • Immediate documentation ensures accuracy and detail retention.

  • Delaying documentation increases risk of forgetting details or missing data altogether.

Content to Avoid in Documentation

• What Not to Document

  • Never document opinions or personal interpretations.

    • For example, do not say, "I think the patient might be in pain."

  • Avoid generalizations.

    • If an event occurs (e.g., a patient falls), document the event factually.

• Example of Proper Documentation:

  • Instead of "Patient fell," state "Patient found lying on the floor."

Key Points to Remember

• Quotation marks for subjective statements.

• Timely documentation is essential for care accuracy.

• Avoid subjective wording in observations.