Proper charting and documentation plays a big role not just in delivering quality patient care but also in high star ratings. Although overwhelming and sometimes confusing, learning to master efficient charting methods will not only make your work easier, but also more efficient and accurate.
The standard expectation is that visit notes must be legible, objective, precise and with correct grammar & spelling– aside from these, here are some pointers to help you deliver excellent documentation:
- Always refer to OASIS— OASIS should always be your companion in every patient visit and in doing your notes. Notes should exhibit an awareness of the physician’s orders and report any progress observed to the physician, the patient and the family.
- Do charting as you do the care. For a more efficient and reliable data set, make an effort to complete discipline notes during–and not after–patient visits.
- Keep your notes CLEAR, SPECIFIC, AND MEASURABLE by following some of these pointers:
- Specify what treatment or intervention is rendered and how it incorporates into the plan of care. Also show how the intervention affected the patient’s health.
- Take notes in a way that a patient case can easily be recalled and recognized by other clinicians working on the patient.
- Make notes succinct and easily understood by Medicare or insurance auditors. The key is to point out the necessity and development of the treatment plan. Explain why a patient needs a particular procedure at a particular time.
- Be specific, use the right words to accurately explain patient’s condition. (e.g. body pain vs. body soreness— soreness doesn’t necessarily mean pain) Learning to use appropriate descriptions can take you a long way.
- Be attentive to signs and indications pertaining to the patient’s health. Scrutinize and take note of new progress and/or occurring pains or complications the patient might have developed.
- Be knowledgeable of your agency’s specific documentation procedures and protocols. It will equip you with useful knowledge in assessing patient cases and health conditions.
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