Kenyon HomeCare ConsultingClinical Documentation: Keeping Your Agency Out Of Hot Water And The Courtroom! - Kenyon HomeCare Consulting (206) 721-5091

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Clinical Documentation: Keeping Your Agency Out Of Hot Water And The Courtroom!

courtroomLet’s talk about the real issues with clinical documentation. In today’s home health and hospice world it is much more than regulations. It is also much more than taking care of the patient. We live in a very litigious society. As an agency owner or administrator, it is important to make sure documentation can stand up in a courtroom. 

4 Tips To Clinical Documentation: 

Nurses and therapists go into the field to take care of people. If your documentation process does not leave a clear and consistent path from admission to discharge, then change workflow. Here are 4 things to help you streamline the process. 

  • Clear Care Plans: Any clinician in that discipline should be able to interpret the interventions regardless of whether the clinician has a homecare background. If this is not the case, then you can’t really show your care plans are effective treating disease process or patient care. 
  • Don’t Omit Important Data: Every licensed professional has heard “If you didn’t document it, then you didn’t do it”. In the healthcare world there is no truer statement. If deposed on patient care, then your documentation is your only guide. You can’t defend your agency or the individual clinician if there is no record of a phone call made or intervention completed. 
  • Consistency: Documentation should be completed in a consistent pattern. Provide clear education to clinicians as to the flow of documentation. Vague documentation is a nightmare. It will always favor the person taking action against the agency. Clearly state interventions and make a clear consistent way for clinicians to document them. 
  • Policies Matching Clinical Practice: If your clinicians document care that is contrary to policy, then the clinician sets herself up for potential malpractice and your agency can’t it. Best practices need maintained and that means your employees need to know how to follow your policies. In addition, review your policies and procedures to ensure it is not so strict that clinicians cannot possible comply. A beautiful policy manual is no good if clinical documentation can’t comply with it. 

Let Us Be Your Guide To Clinical Documentation:

At Kenyon Homecare Consulting, we specialize in clinical and operational processes with senior associates who can streamline and teach documentation. Call us today at 206-721-5091 or contact us online to see how we can put all the pieces of the documentation puzzle fit. 


Category: Documentation

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