Documentation in the medical record is essential. It provides a chronological record of the residents’ experiences while in your care, including the services provided to meet their needs and achieve their highest practicable well-being as required by the Centers for Medicare & Medicaid Services (CMS).
This information is used to create and manage treatment and care plans. It is also a legal record that may be used in risk management and in defense for litigation, making it crucial to meet criteria for professional documentation standards. Just as important, it is a mechanism for communicating information about past and current medical and functional resident status between caregivers and across disciplines and care settings.
Leadership has a responsibility to ensure that staff provide clear, concise, objective and timely documentation that meets professional standards. Processes related to consistent training on expectations and evaluating the quality of documentation help ensure competencies.
Comagine Health has launched a six-part affinity group series that explores the nuances of early detection of and intervention for changes in resident condition, and reinforces the link between staff resiliency and patient safety, specifically focusing on how interventions that prioritize the well-being of both residents and staff members often lead to the best outcomes. The webinars are unrecorded open forums to facilitate sharing and innovation.
On July 9, a group of providers from about 31 long-term and post-acute care facilities attended the fifth session, “Documenting Interventions and Resident Response to Care,” where they offered their tips, tools and best practices regarding this important component of coordinating and providing quality care. Additionally, teams explored the importance of fostering a culture that supports psychological safety. Comagine Health has compiled their feedback and created a resource for your facility to reference.
As the series goes on, we will continue to curate the insights gained from these affinity group discussions, which will include session highlights, practice ideas from partners and actionable next steps you can bring back to your staff to begin growing skills and making improvements.
Don’t miss our next session in the Looking Beyond COVID-19: Detecting Change in Resident Condition and the Impact of Staff Resiliency series on Aug. 13: QI Review of Transfers, Drivers of Admissions/Readmissions.