Okay, I've Got the Basics, Now What?

Other information that needs to be recorded in the medical record includes any education or instructions you give to the client, his family or significant other. A pre-printed, standardized check off form may be used where all you have to do is check off or initial what you have done. The only time you may have to write any notes is when something is specific or unique to this particular client, something that can't be included on a standardized check off form. Check off forms are great as they save all kinds of documentation time, but remember: if you do not check off items as required, it means that legally the care was not done.

Anytime a client, family member or significant other is given a referral to a community resource, it should be recorded. And it is obvious that any authorization or consent for treatment is a documentation priority so that legally, permission to provide care has been given.

You're right, there's more to record even if what we are now going to talk about now does not get recorded into the medical record per se. I'm referring to phone calls that we receive. We don't often think about phone calls but they can contain certain information for which we have obligations such as advice that we may give to a client or a phone order that we may take from a doctor. To protect yourself in these kinds of phone conversations, a telephone log is recommended to record these client and/or physician calls. The log can be retrieved to refresh your memory and provide evidence if the need arises.

Pre-printing such a log so that all you have to do is record the required information is optimal. The respective logs should include the following information (NSO, 2020):

For a Client Call
  • Date and time of call
  • Caller's name and address
  • Caller's request or chief complaint
  • Advice you gave
  • Protocol you followed (if any)
  • Other caregivers you notified
  • Your name
For a Patient Call
  • Date and time of call
  • Physician's name and "T/O" to indicate order
  • Verbal order, written word-for-word
  • Documentation that you've read back the order, to be sure you heard it correctly
  • Documentation that you've transcribed it according to your facility's policy
  • Your name