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Ensure Better Service Documentation with These Tips

service documentation

Home care service documentation is crucial to any agency. Not only does accurate documentation lead to better patient care and family communication, but service documentation also ensures your agency is correctly reimbursed. In short, without solid documentation practices and follow-through, your agency will quickly lose money and clients. Fortunately, you can create good habits for your caregivers and for your leadership staff with a few of our tips.

Start with Thorough Training

Good documentation habits begin with thorough training during the orientation process. You should devote a section of your orientation training curriculum to successful documentation. Don’t just include how to document (though that is certainly important), but also include why documentation is important. Your caregivers are more likely to focus on correct service documentation when they realize you use their input to create person-centered care plans and to follow up with family members. Empower them by letting them know that their documented observations can lead to better client care.

Let Caregivers Practice

While documentation is similar across the senior care industry, don’t assume that all caregivers know how to correctly document. Instead, give them time to practice documentation skills at least twice per year during a skills check in-service. During this time, create scenarios and have them practice documenting the incident. Remind them to use best practices like documenting what they observed happen, not what they think happened, as well as not using “text-speak” while writing in the paper or electronic medical chart.

Shadow a Mentor

Any new caregiver to your agency should have the opportunity to shadow an experienced caregiver Mentor at least a few times in the client’s home. During this time, ensure the new caregiver has the chance to observe the Mentor documenting as well as to have the Mentor observe the new caregiver documenting. This extra step ensures all new caregivers get to know the documentation system in place for your agency as well as learns the foundations of proper and accurate documentation.

Consider Going Electronic

If your agency is not yet using an app for remote documentation, begin considering if it is a feasible option for your business. Apps are easy to use and home care platforms ensure confidentiality as well as HIPAA compliance. Further, most caregivers already have a personal smartphone which makes an app even more realistic for continuous use. Finally, apps ensure care plans and documentation is updated in real-time, giving you and other leadership staff the chance to “see” what is happening with a patient as it occurs.

Audit Frequently

Finally, ensure the leadership team is taking turns auditing documentation regularly. Consider having each leader audit 2-5 randomly chosen charts monthly. This will not take too much time and is well worth the ongoing effort, as you can quickly see when documentation is lacking or what trends to address during your next all-staff communication.

Service documentation is an important part of your agency and with a few training adjustments and a commitment to consistent auditing, you can rest assured that your caregivers are keeping up with best practices.

Article written by Haley Burress.

Hi, my name is Wendell Scott and I help Home Care Agencies who are experiencing high caregiver turnover rates, have trouble coordinating client care and feel frustrated with their team to easily increase efficiency and scale their Home Care business.

I’d like to share with you my free Caregiver Recruitment Engine framework. In it, are the tools to help you develop a system to easily attract & hire caregivers (aka a repeatable system for recruiting quality staff), so you can organize your process, reliably recruit staff and efficiently scale your home care team.

The end result: 

Hire caregivers.

Faster than ever. 



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