New to PDN

I've read from the Medicaid package that proper documentation is required. I have written down nurses notes on a notebook but I have a feeling that that may not be enough. I've read from others that they only bring a notebook. The clients family didn't seem concerned at all about nurses notes/documentation of what I did or the patients status and they've had independent medicaid providers before.

Then you are working for a medicaid entity and not doing private duty for a private pay patient. Medicaid is the third party here, unless there is also an agency involved. You have to do what they tell you. Surprised that the client has not clued you in.

Sorry. Wrong choice of words.

"You have to do what they tell you" - you mean the client and her family?

Well, they weren't really specific about the things I should do other than attend to their mother's need. I'm just concerned about documentation. I don't want to have a problem with lack or insufficient documentation

Thanks for the responses. I'm not contracted with any agency nor is the client.

I've worked Medicaid cases before and like PP have said, a communication book is what some use. I was the primary on my last case and I'm in the process of opening a new one. In these instances, I treated the documentation like I would at an agency. I typed out the Meds and what diagnosis they were associated with. I typed out his initial "assessment" (fact-finding worksheet), and his therapy schedule. I requested specific names of each of the PROM exercises PT did with him so I could go out and find photos online with instructions. I placed all these in a binder with dividers. Then I kept a nursing journal that I requested all nurses document in every shift. The family didn't require it, but I knew that when it came time to recertify his hours all the supporting documentation would help him maintain eligibility or even increase his benefit. This of importance to the patient and the nurses who depend on the case for income! I've seen normally qualified kiddos lose hours because their condition was not properly documented on an ongoing basis. An examiner is looking at the here and now, when approving hours and sometimes the kid is stable at that time (from the great home care they receive!) but an examiner can't argue with six months of supporting documentation showing both the "good days" and the "bad days". Document, document, document, even in (especially in) PDN! JMHO.