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Discussion

Documentation guidelines

Hello everyone! I'm currently helping an agency with review and improve their documentation. After review several of the patients charts I noticed that there is no documentation of any education. Now, I know that the nurses are educating on something. How can you do a home health visit and not educate on something? Its not possible, but the nurses are not documenting their education.

When I send message to them about corrections their response is.......I completed a skill so I do not need documentation.

The agency that I previously worked for required documentation of education on every visit. Plus, as I stated above, as a nurse you are constantly educating patients. Why not document what you are already doing?

So my question is.....Should there be documentation of education at every visit for the note to compliant with state agencies? If so, can you point me in the direction of this documented somewhere? I've looked and I'm having trouble finding this information.

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    One time a supervisor at the home health agency (at the time) addressed education, saying it was a requirement. It happened that I documented education, but not for every shift, (I was working extended care). Other agencies since that time have not made the request, but I still look for topics to document. To me it is just easier to meet the requirement, although after years on service, I am certain that many extended care clients can recite the spiel word for word. Surprisingly, I have found education more difficult with visit clients. Some of my visit clients would not let me get a word in edgewise due to their level of engagement. It seems to me that I saw the requirement in writing one time but I don't refer to that material often enough to be able to quote it. You can probably find it with a search. That info has been mentioned on the site in the past.

    For visit clients, I documented education at every visit. For extended care clients, almost every shift, unless there is something extenuating for which I can chart a reason to forego this entry (night shift is a reason).

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