In any business industry there is always one important rule to follow; document everything. Even if a task or assignment has been completed, if it is not properly documented, “it never happened.” While this can be frustrating, this is how businesses operate; especially, in the medical field.
Imagine working in an assisted living facility, where you are responsible for providing personal and medical assistance to a number of residents. During your regular shift you are to bath or shower each resident, serve themlunch, assist them with their medication and escort them to physical therapy. At the end of your shift, you are all set to go home, when your replacement arrives.
You are asked specific questions, you might not remember right off, so you look in the facility log, only to find it blank. Why? Because you have failed to document all the tasks you were assigned to. Imagine if a family member believes that their loved one was not bathed or given medication. What proof do you have that you actually gave that particular resident the right medication?
Unless you document every aspect of your job, as you perform it, there is no other way to prove that you successfully completed your job.
Did you know that in cases of abuse or neglect, the court will ask to see documentation notes? Documentations are used to validate or dismiss a case. Before insurance companies pay any portion of a medical bill, or agree to pay for any special procedures, they want proof. This includes showing a form of documentation, which outlines when and how care was given, who administered it, the diagnosis and the prescribed follow up recommendation.
If the work you have done is not detailed in black and white, with your initials close by, you may have to repeat the procedures or tests again or accept a loss. In the best interest of caregiver, their employers, the families and their family members, it is always good practice to document each form of care, after the procedure has been performed.
It is best to make documentation notes prior to leaving the room. There may not be an opportunity to go back later and write it down. Your notes are proof that personal, professional and medical care was given to residents during regular set hours, by an approved facilitated caregiver.