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Documentation! What, When, Why?

In non-medical home care, you're not necessarily nurses and you don't have to document like one. However, it's still important to document what goes on in the agency with your clients (and their families), staff and your caregivers. Develop a system to document anything that could affect your agency, the client's care and your staff. It needs to be documented in some way, simply for transparency.

For instance, what happens if you're the one running your agency and the majority of the conversations with you are great! But, you also have a backup person. If you're not documenting all the conversations that you're having with family members, clients, and caregivers, about little things that are actually affecting care, then what happens if you get sick? I used to say, “What happens if I get hit by a bus?” Or some people say, “What if I hit the lottery and take off?” The information that's in your head needs to be accessible to anyone else who might be in charge of taking care of those people. That sounds kind of “doomsday-ish”, but for transparency purposes, if you're not a team of just one, I highly recommend you document somewhere in your system.

When I'm talking about documenting I personally make note of conversations with everybody because I want to know, What happened yesterday, last week, or last month? I should be able to look into my client's record and see everything. And as you grow, keeping a "it's all in my head" filing system is NOT scalable!

Incidents. This is anything that's really not on the care plan. If something happens like a fall, even a controlled fall, such as hitting a table and breaking a lamp while vacuuming is an incident. A client forgot their medications and you noticed, that's an incident. Finding a bruise on someone’s arm is an incident even if it's not something that happened with you. The facts would be what you discovered, what you saw, what you know, or what you were told. You're not going to want to speculate and make assumptions. Just report what you see. Incidents you may witness include occurrences, family drama, little dynamics and incidents with the client that your caregivers might call you about. It might seem insignificant in the moment, but it might be really important later. It’s always best to keep track.

If an incident does happen, document! Ask your staff to fill out an incident report and send it in. But what happens if they don't? What happens if they mail it and you don't get it for 10 days by snail mail? It's a good idea to ask them to send in a report because you always want their statement. But it’s a better idea to go ahead and initiate that report in the office. Then when you receive their documentation, you’ll have both yours and theirs. If theirs is sufficient, that's fine but when it comes down to documentation of incidents and such, the state holds you accountable, not your staff.

Pay attention to feedback. Feedback about clients from caregivers about clients, and from clients about caregivers- both positive and negative are important. And maybe it's because you're getting the same feedback about that caregiver with every client you send them to, or maybe you're getting the same feedback about that client from every caregiver that goes out there. You need to be able to identify those patterns and make sure that you're doing the best for your clients and your employees.

Examples of negative and positive feedback are a client calling and saying they "really loved a particular fill-in caregiver and they want her to come back as often as possible." That’s great! Send her a little note card to acknowledge her and remember to document those positive comments in her file!

Acknowledgment is important too! Many times our best caregivers never hear from us. If they're low maintenance, they're not the squeaky wheel, so they don't get the grease. It’s important that they do hear back from us especially when something goes well.

Complaints (sometimes negative feedback are true complaints). You will need to determine for yourself what that means and what that looks like. Those have to be documented and addressed.

Client satisfaction: Everybody defines client satisfaction a little differently. Whether it's a sampling monthly or quarterly, or you send out a survey once a year. Whether it's on paper or electronic link or both, that does need to be documented.

When a client goes to a hospital and then subsequently when they're discharged, document! It needs to be documented in the system because oftentimes there's going to be some sort of change in condition, or there was an occurrence that caused the hospitalization. Or, they're just going in for a scheduled surgery, but still their care plan might be different when they discharge. Everybody needs to be aware.

Not to mention the fact that when somebody goes to the hospital, that's a good opportunity to visit the case managers and see your client, that’s just good marketing.

Update care plans. When there are hospital/rehab discharges it’s important to update care plans (ISP). For example, if the client comes home with PT, adding "assist with PT Exercises" should be added. Or if they have a new diet regimen because of a new diagnosis, or any changes related to an infection, if monitoring or helping to prevent reinfection affects the way you're providing care.

Updates would also include any sort of change in condition, even changes in behaviors - some of which can be acute and need to be addressed by a doctor. For example, a Caregiver reports: “A few weeks ago, when I first started with her, she could walk just fine with her walker. Now I have to hold on to her walking because she's about to fall.” That's a change in condition that you need to be aware of.

A change in schedule: Whether it's a cancellation or an addition of an extra shift or the schedule changes altogether, it has to be documented in the system. An example of a change is shifting from mornings to afternoons. Or, it was days now it's nights, or we've added shifts. Document any changes because you can't just change the schedule and assume that somebody is going to know when and why. It's important to have documentation to support that your client made that request, and your agency didn't make the change without cause.

You also want to educate your staff on what to report to you. Then observe, especially in the beginning, what kind of information they're sending you. When you first orient them, when you introduce them to their client, when you do regular check-ins with the caregivers regarding their client, and when you're doing your supervisory visits, observe and document.

With Caregivers, you're always giving the message that they are accountable to the agency for their clients' wellbeing. Say things like:

  • “I want you to report anything out of the ordinary to me."

  • "I'm trusting you to go out into this client's home. And they trusting us with their care, but I don't know what's happening if you don't tell me."

  • "It’s important to follow through so we're all on the same team.”

To wrap it up, my suggestion is to be vigilant about regularly documenting and having a system. Hold yourself accountable to document so that you can share that with others. And of course, you're also going to want to document any kind of emergencies. Guess what? This information is helpful when you're doing your Q.A.P.I.!

If you have any questions, reach out.

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