charting medical necessity???

I work as a caregiver at a LTC facility for adults with disabilities. whenever 1:1 with a patient we are required to fill out documentation detailing why the patient needed to be one on one.

So, for example, if I was scheduled to be 1:1 with a patient for four hours, I would detail what I did in those four hours.

example:

"Staff spent four hours with client. Staff transfered client from the wheelchair via pivot transfer and from the wheelchair to the toilet again via pivot transfer; this process occurred twice. Staff provided cues about surrounding to client, including time, location, and client's current status in the program"

That's just an example. My point is that the purpose of the documentation is to get across the point that "yes this client did need 1:1 care. and this is the care they got during the time I was with them."

Hope that helps.