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.

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