Content Outline
I. Why Is There So Much Hoopla About Documentation Anyway?
A. State Regulations
B. Federal Regulations
C. Client History
D. Reimbursement Issues
E. Protection at Litigation
II. What Basic Information Should I Be Sure to Document in the Medical
Record?
A. Chronology: Date and Time
B. Client History
C. Interventions: Medical, Social and Legal
D. Observations: Objective and Subjective
E. Outcomes
F. Client and Family Response
G. Authorship: Your Signature and Credentials
III. Okay, I’ve Got the Basics. Now What?
A. Client/Family Education/Instructions
B. Referrals to Community Resources
C. Authorizations and Consents
D. Plans for Follow-up
E. Discharge Plan
F. Telephone Calls: Be Specific
IV. I’m Worried About Faxes and Computerized Records. What Do I Need to
Know About Them?
A. Facts on Faxing Records
B. Computer Charting
V. Can You Make Documentation Easier for Me?
A. The Do’s
B. The Don’ts
VI. What Is the Difference in How a Nurse Documents versus How a Certified
Nursing Assistant Should Document?
A. Nurses: Nursing Process and Outcomes as Guidelines
B. CNAs: Flow Charts and Check-Off Lists
VII. How Can I Be Sure that My Documentation is Satisfactory?
A. Let’s Develop a Working List of Positive Characteristics.
VIII. Can You Give Me Some Examples of Where Documentation Went
Wrong?
A. Sure Thing! Would a review of some legal situations help?
IX. What’s Does the Future Hold?
