Download clinical documentation in home health care

CLINICAL DOCUMENTATION IN HOME HEALTH
CARE
SUPPLEMENT
LICENSURE/BOARD COMPLAINT
COMPLAINT
INVESTIGATION
DISCIPLINE
DOCUMENTATION CLASES
LITIGATION
IF YOU DIDN’T WRITE IT DOWN, IT DIDN’T
HAPPEN
EXPLAINING/TESTIFYING BASED ON
MEMORY
DOCUMENTATION BY INCLUSION OR
EXCLUSION
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NARRATIVE DOCUMENTATION
FACTUAL
AVOID ADVERBS, ADJECTIVES, OPINIONS,
AND CRITICISMS
LATE ENTRIES
ATTRIBUTION
EXPLANATION
DATE AND TIME
OF THE ORIGINAL ENTRY
OF THE LATE ENTRY
MARGIN ENTRIES
IF IT IS IMPORTANT ENOUGH TO
WRITE IT DOWN, THEN IT IS
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WHITE OUTS
PLEASE DON’T!
CNA
R4-19-813. Performance of Nursing Assistant Tasks\
A. A certified nursing assistant may perform the following:
d. Assessment, interpretation, or decision-making is not required during the
performance or at the completion of the task.
B. A nursing assistant may not perform any task that requires a judgment based on
nursing knowledge, such as the administration of medications.
C. A nursing assistant shall:
7. Observe, report, and record signs, symptoms, and changes in the patient or resident's
condition in an ongoing and timely manner; and
R4-19-814. Standards of Conduct for Certified Nursing Assistants
For purposes of A.R.S. § 32-1601(16)(d), a practice or conduct that is or might be
harmful or dangerous to the health of a patient or the public and constitutes a basis for
disciplinary action on a certificate includes the following:
4. Failing to accurately document care and treatment provided to a patient or resident;
5. Falsifying or making a materially incorrect entry in a health care record;
8. Failing to report signs, symptoms, and changes in patient or resident conditions to the
immediate supervisor in an ongoing and timely manner;
LPN
R4-19-401. Standards Related to Licensed Practical Nurse Scope of Practice
D. In participating in the nursing process and implementing client care across the
lifespan, a LPN shall:
1. Contribute to the assessment of the health status of clients by:
b. Gathering and recording assessment data;
c. Demonstrating attentiveness by observing, monitoring, and reporting signs,
symptoms, and changes in client condition in an ongoing manner to the supervising
registered nurse or physician;
2. Contribute to the development and modification of the plan of care by:
a. Planning episodic nursing care for a client whose condition is stable or
predictable;
3. Implement aspects of a client's care consistent with the LPN scope of practice
in a timely and accurate manner including:
f. Communicating relevant and timely client information with other health team
members regarding:
i. Client status and progress,
ii. Client response or lack of response to therapies,
iii. Significant changes in client condition, and
iv. Client needs and special requests, and
g. Documenting the nursing care the LPN provided;
4. Contribute to evaluation of the plan of care by:
a. Gathering, observing, recording, and communicating client responses to
nursing interventions; and
b. Modifying the plan of care in collaboration with a registered nurse based on an
analysis of client responses.
RN
R4-19-402. Standards Related to Registered Nurse Scope of Practice
C. In utilizing the nursing process to plan and implement nursing care for clients across
the life-span, a RN shall:
4. Provide nursing care within the RN scope of practice in which the nurse:
a. Administers prescribed aspects of care including treatments, therapies, and
medications;
b. Clarifies health care provider orders when needed;
c. Implements independent nursing activities consistent with the RN scope of
practice;
d. Institutes preventive measures to protect client, others, and self;
e. Intervenes on behalf of a client when problems are identified;
f. Promotes a safe client environment;
g. Attends to client concerns or requests;
h. Communicates client information to health team members including:
i. Client concerns and special needs;
ii. Client status and progress;
iii. Client response or lack of response to interventions; and
iv. Significant changes in client condition; and
i.
Documents the nursing care the RN has provided;
R4-19-403. Unprofessional Conduct
For purposes of A.R.S. § 32-1601(16)(d), any conduct or practice that is or might be
harmful or dangerous to the health of a patient or the public includes one or more of the
following:
7. Failing to maintain for a patient record that accurately reflects the nursing
assessment, care, treatment, and other nursing services provided to the patient;
8. Falsifying or making a materially incorrect, inconsistent, or unintelligible entry
in any record:
a. Regarding a patient, health care facility, school, institution, or other work place
location; or
b. Pertaining to obtaining, possessing, or administering any controlled substance
as defined in the federal Uniform Controlled Substances Act, 21 U.S.C. 801 et seq., or
Arizona's Uniform Controlled Substances Act, A.R.S. Title 36, Chapter 27;
NURSE PRACTITIONER
R4-19-508. Scope of Practice of a Registered Nurse Practitioner
B. In addition to the scope of practice permitted a registered nurse, a registered nurse
practitioner, under A.R.S. §§ 32-1601(15) and 32-1606(B)(12), may perform the
following acts within the limits of the specialty area of certification:
1. Examine a patient and establish a medical diagnosis by client history, physical
examination, and other criteria;
2. For a patient who requires the services of a health care facility:
a. Admit the patient to the facility,
b. Manage the care the patient receives in the facility, and
c. Discharge the patient from the facility;
3. Order and interpret laboratory, radiographic, and other diagnostic tests, and
perform those tests that the RNP is qualified to perform;
4. Identify, develop, implement, and evaluate a plan of care for a patient to
promote, maintain, and restore health;
5. Perform therapeutic procedures that the RNP is qualified to perform;
6. Prescribe treatments;
7. If authorized under R4-19-511, prescribe and dispense drugs and devices; and
8. Perform additional acts that the RNP is qualified to perform.
ALLIED HEALTH PROFESSIONALS
RESPIRATORY THERAPY
R4-45-214. Standards of Professional Conduct
Conduct or practice that is contrary to recognized standards of ethics of the respiratory
therapy profession, as used in A.R.S. § 32-3501(10)(i), includes the following:
16. Inaccurately recording, falsifying, or altering a patient record, including a patient
chart or medication administration record;
OCCUPATIONAL THERAPY
R4-43-101. Definitions
5. "Immorality or misconduct that tends to discredit the occupational therapy profession"
means:
c. Falsifying patient or client documentation or reports.
f. Failing to document or maintain patient treatment records, or failing to prepare patient
or client reports within 30 days of service or treatment.
k. Signing a blank, undated, or unprepared prescription form.
R4-43-401. Supervision of Occupational Therapy Assistants
A. Only a licensed occupational therapist shall:
1. Prepare an initial treatment plan, initiate or re-evaluate a client or patient's
treatment plan, or authorize in writing a change of a treatment plan;
R4-43-402. Supervision of Occupational Therapy Aides and Other Unlicensed
Personnel
D. An occupational therapy aide shall not perform the following tasks:
2. Prepare a treatment plan;
3. Make entries in client or patient record regarding client or patient status;
PHYSICAL THERAPY
R4-24-301. Lawful Practice
A. A physical therapist shall provide the referring practitioner, if any, with information
from the patient assessment, diagnosis, and plan of care. Within one week after a patient
is initially evaluated, the physical therapist shall provide this information:
1. In writing and place a copy of the written notice in the patient's record, or
2. Orally and place a contemporaneously made note of the verbal communication in the
patient's record.
B. A physical therapist shall maintain the confidentiality of patient records as required by
federal and state law.
C. On written request by a patient or the patient's health care decision maker, a physical
therapist shall provide access to or a copy of the patient's medical or payment record in
accordance with A.R.S. § 12-2293.
D. A physical therapist shall obtain a patient's consent before examination and treatment
and document the consent in the patient's record.
R4-24-303. Patient Care Management
A. A physical therapist is responsible for the scope of patient management in the practice
of physical therapy as defined by A.R.S. § 32-2001. For each patient, the physical
therapist shall:
1. Perform and document an initial evaluation;
2. Perform and document periodic reevaluation;
3. Document a discharge summary and the patient's response to the course of treatment at
discharge;
4. Ensure that the patient's physical therapy record is complete and accurate; and
5. Ensure that services reported for billing, whether billed directly to the patient or
through a third party, are accurate and consistent with information in the patient's
physical therapy record.
B. On each date of service, a physical therapist shall:
1. Perform and document each therapeutic intervention that requires the expertise of a
physical therapist; and
2. Determine, based on a patient's acuity and treatment plan, whether it is appropriate to
use assistive personnel to perform a selected treatment intervention or physical therapy
task for the patient.
F. A physical therapist who provides general supervision for a physical therapist assistant
shall:
1. Be licensed under this Chapter;
2. Respond to a communication from the physical therapist assistant within 15 minutes;
3. Go to the location at which and on the same day that the physical therapist assistant
provides a selected treatment intervention if the physical therapist, after consultation with
the physical therapist assistant, determines that going to the location is in the best interest
of the patient; and
4. Perform a reevaluation and provide each therapeutic intervention for the patient that is
done on the day of the reevaluation every fourth treatment visit or every 30 days,
whichever occurs first.
G. A physical therapist assistant who provides a selected treatment intervention under
general supervision shall document in the patient record:
1. The name and license number of the supervising physical therapist;
2. The name of the patient to whom the selected treatment intervention is provided;
3. The date on which the selected treatment intervention is provided;
4. The selected treatment intervention provided; and
5. Whether the physical therapist assistant consulted with the supervising physical
therapist during the course of the selected treatment intervention and if so, the subject of
the consultation and any decision made.
R4-24-304. Adequate Patient Records
A. A physical therapist shall ensure that a patient record meets the following minimum
standards:
1. Each entry in the patient record is:
a. Legible,
b. Accurately dated, and
c. Signed with the name and legal designation of the individual making the entry;
2. If an electronic signature is used to sign an entry, the electronic signature is secure;
3. The patient record contains sufficient information to:
a. Identify the patient on each page of the patient record,
b. Justify the therapeutic intervention,
c. Document results of the therapeutic intervention,
d. Indicate advice or cautionary warnings provided to the patient,
e. Enable another physical therapist to assume the patient's care at any point in the course
of therapeutic intervention, and
f. Describe the patient's medical history.
4. If an individual other than a physical therapist or physical therapist assistant makes an
entry into the patient record, the supervising physical therapist co-signs the entry;
5. If it is determined that erroneous information is entered into the patient record:
a. The error is corrected in a manner that allows the erroneous information to remain
legible, and
b. The individual making the correction dates and initials the correct information; and
6. For each date of service there is an accurate record of the physical therapy services
provided and billed.
B. Initial evaluation. As required by A.R.S. § 32-2043(F)(1), a physical therapist shall
perform the initial evaluation of a patient. The physical therapist who performs an initial
evaluation shall make an entry that meets the standards in subsection (A) in the patient
record and document:
1. The patient's reason for seeking physical therapy services;
2. The patient's relevant medical diagnoses or conditions;
3. The patient's signs and symptoms;
4. Objective data from tests or measurements;
5. The physical therapist's interpretation of the results of the examination;
6. Clinical rationale for therapeutic intervention;
7. A plan of care that includes the proposed therapeutic intervention, measurable goals,
and frequency and duration of therapeutic intervention; and
8. The patient's prognosis.
C. Therapeutic-intervention notes. For each date that a therapeutic intervention is
provided to a patient, the individual who provides the therapeutic intervention shall make
an entry that meets the standards in subsection (A) in the patient record and document:
1. The patient's subjective report of current status or response to therapeutic intervention;
2. The therapeutic intervention provided or appropriately supervised;
3. Objective data from tests or measures, if collected;
4. Instructions provided to the patient, if any; and
5. Any change in the plan of care required under subsection (B)(7).
D. Re-evaluation. As required by A.R.S. § 32-2043(F)(2), a physical therapist shall
perform a re-evaluation when a patient fails to progress as expected, progresses
sufficiently to warrant a change in the plan of care, or in accordance with R4-24303(F)(4). A physical therapist who performs a re-evaluation shall make an entry that
meets the standards in subsection (A) in the patient record and document:
1. The patient's subjective report of current status or response to therapeutic intervention;
2. Assessment of the patient's progress;
3. The patient's current functional status;
4. Objective data from tests or measures, if collected;
5. Rationale for continuing therapeutic intervention; and
6. Any change in the plan of care required under subsection (B)(7).
E. Discharge summary. As required by A.R.S. § 32-2043(F)(3), a physical therapist shall
document the conclusion of care in a patient's record regardless of the reason that care is
concluded.
1. If care is provided in an acute-care hospital, the entry made under subsection (C) on
the last date that a therapeutic intervention is provided constitutes documentation of the
conclusion of care if the entry is made by a physical therapist.
2. If care is not provided in an acute-care hospital or if a physical therapist does not make
the entry under subsection (C) on the last date that a therapeutic intervention is provided,
a physical therapist shall make an entry that meets the standards in subsection (A) in the
patient record and document:
a. The date on which therapeutic intervention terminated;
b. The reason that therapeutic intervention terminated;
c. Inclusive dates for the episode of care being terminated;
d. The total number of days on which therapeutic intervention was provided during the
episode of care;
e. The patient's current functional status;
f. The patient's progress toward achieving the goals in the plan of care required under
subsection (B)(7); and
g. The recommended discharge plan.
SOCIAL WORK
Board of Behavioral Health Examiners
ARTICLE 11. STANDARDS OF PRACTICE
A licensee shall:
1. Provide treatment to a client only in the context of a professional relationship based on
valid informed consent for treatment;
2. Document in writing for each client served the following elements of informed consent
for treatment:
a. Purpose of treatment;
b. General procedures to be used in treatment, including benefits, limitations, and
potential risks;
c. A client's right to have client records and all information regarding the client kept
confidential and an explanation of the limitations on confidentiality;
d. Notification of the licensee's supervision or involvement with a treatment team of
professionals;
e. Methods for a client to obtain information about the client's records;
f. The client's right to participate in treatment decisions and in the development and
periodic review and revision of the client's treatment plan;
g. A client's right to refuse any recommended treatment or to withdraw informed consent
to treatment and to be advised of the consequences of such refusal or withdrawal; and
h. The client's right to be informed of all fees that the client is required to pay and the
licensee's refund and collection policies and procedures.
3. Obtain a dated and signed informed consent for treatment from a client or a client's
legal representative before providing treatment to a client.
4. Inform a client of the limitations and risks associated with providing treatment via
electronic media before providing such services;
5. Obtain a dated and signed informed consent for treatment from a client or a client's
legal representative before providing treatment to the client via electronic media; and
6. Obtain a dated and signed informed consent for treatment from a client or a client's
legal representative before audio or video taping a client or permitting a third party to
observe treatment provided to a client.
R4-6-1102. Treatment Plan
A licensee shall:
1. Work jointly with each client served or a client's legal representative to prepare an
integrated, individualized, written treatment plan, based on the licensee's diagnosis and
assessment of behavior and the treatment needs, abilities, resources, and circumstances of
the client, that includes:
a. One or more treatment goals;
b. One or more treatment methods;
c. The date when the client's treatment plan shall be reviewed;
d. If a discharge date has been determined, the aftercare needed after discharge;
e. The signature and date signed by the client or the client's legal representative; and
f. The signature and date signed by the licensee.
2. At a minimum, review and reassess the treatment plan according to the review date
specified in the treatment plan and at least annually with each client or the client's legal
representative to ensure the continued viability and effectiveness of the treatment plan
and, where appropriate, a description of the services the client may need after terminating
treatment with the licensee.
3. Ensure that all treatment plan updates and revisions include the signature and date
signed by the client or the client's legal representative and the signature and date signed
by the licensee.
4. Upon written request, provide a client or a client's legal representative an explanation
of all aspects of the client's condition and treatment.
5. Ensure that a client's treatment is in accordance with the client's treatment plan.
R4-6-1103. Client Record
A. A licensee shall ensure that a client record is maintained for each client and:
1. Is protected at all times from loss, damage or alteration;
2. Is confidential;
3. Is legible and recorded in ink or electronically recorded;
4. Contains entries that are dated and signed with the first and last name of the individual
signing the document or electronically authenticated by the individual making the entry;
5. Is current and accurate;
6. Contains original documents and original signature, initials or authentication; and
7. Is disposed of in a manner that protects client confidentiality.
B. A licensee shall ensure that a client record contains the following, if applicable:
1. The client's name, address, and home telephone number;
2. Documentation of informed consent to treatment;
3. Documentation of the treatment plan and all updates and revisions to the treatment
plan;
4. Information or records provided by or obtained from another person regarding the
client;
5. Written authorization to release a client record or information;
6. Documentation of requests for client records and of the resolution of those requests;
7. Documentation of the release of any information in the client record;
8. Progress notes;
9. Documentation of telephone, written, or face-to-face contact with the client or another
individual that relates to the client's health, safety, welfare, or treatment;
10. Documentation of behavioral health services provided to the client;
11. Other information or documentation required by state or federal law.
12. Financial records, including:
a. Records of financial arrangements for the cost of providing behavioral health services;
b. Measures that will be taken for nonpayment of the cost of behavioral health services
provided by the licensee.
C. A licensee shall make client records in the licensee's possession promptly available to
another health professional, the client or the client's legal representative in accordance
with A.R.S. § 12-2293.
D. A licensee shall make client records of a minor client in the licensee's possession
promptly available to the minor client's parent in accordance with A.R.S. § 25-403(H).
E. A licensee shall retain records in accordance with A.R.S. § 12-2297.
F. A licensee shall ensure the safety and confidentiality of any client records the licensee
creates, maintains, transfers, or destroys whether the records are written, taped,
computerized, or stored in any other medium.
G. A licensee shall ensure that a client's privacy and the confidentiality of information
provided by the client is maintained by subordinates, including employees, supervisees,
clerical assistants, and volunteers.
H. A licensee shall ensure that a progress note includes the following:
1. The date a behavioral health service was provided;
2. The duration of time spent providing the behavioral health service;
3. If counseling services were provided, whether the counseling was individual
counseling, family counseling or group counseling; and
4. The signature and date signed by the licensee who provided the behavioral health
service.
R4-6-1104. Financial and Billing Records
A licensee shall:
1. Make financial arrangements with a client, a client's legal representative, third party
payor or supervisee that are reasonably understandable and conform to accepted billing
practices;
2. Before entering a therapeutic relationship, clearly explain to each client or the client's
legal representative, all financial arrangements related to professional services, including
the use of collection agencies or legal measures for nonpayment;
3. Truthfully represent financial and billing facts to a client, a client's legal representative,
third party payor or supervisee regarding services rendered; and
4. Maintain separate written or electronic billing records that correspond with the client
record.
R4-6-1105. Confidentiality
A. A licensee shall only release or disclose client records or any information regarding a
client:
1. In accordance with applicable federal or state law that authorizes release or disclosure;
or
2. With written authorization from the client or the client's legal representative.
B. A licensee shall ensure that written authorization for release of client records or any
information regarding a client is obtained before a client record or any information
regarding a client is released or disclosed unless otherwise allowed by state or federal
law.
C. Written authorization includes:
1. The name of the person disclosing the client record or information;
2. The purpose of the disclosure;
3. The individual, agency, or entity requesting or receiving the record or information;
4. A description of the client record or information to be released or disclosed;
5. A statement indicating authorization and understanding that authorization may be
revoked at any time;
6. The date or circumstance when that authorization expires, not to exceed 12 months;
7. The date the authorization was signed; and
8. The signature and date signed by the client or the client's legal representative.
D. A licensee shall ensure that written authorization to release a client record or any
information regarding a client is maintained in the client record.
E. Where a licensee provides behavioral health services to more than one person in a
family, each family member who is legally competent to consent to authorize release of
client records shall sign a written authorization to release client records regarding that
family member or any information obtained from that family member. Without such an
authorization, a licensee shall not disclose that family member's client record or any
information obtained from that family member.