As HealthCap educational offerings continue to grow it is interesting that many facilities request additional training on documentation basics.  In an effort to meet this need, HealthCap has developed an in-service series on documentation that focuses on specific health issues including constipation and dehydration. 

Documentation is a critical component in supporting that appropriate care is provided to our residents. That said, as an industry we spend little time monitoring the quality of what is being written in the medical record.  The old adage “if it isn’t written it wasn’t done” continues to haunt defense attorney’s around the country.  Faced with providing “proof” that appropriate care was provided to a resident is difficult if the documentation isn’t there or is inaccurate.  Every caregiver should be trained on documentation basics including timing of entries, legible handwriting, objective, concise entries, etc.  However, knowing and doing are two different things and the responsibilities of managing a nursing unit may often lead to taking shortcuts in documentation.

There are many educational opportunities available to HealthCap members including on-site educational in-services and a video lending library.  Also, new for 2011, HealthCap University is now available to all members!  HealthCap University is a web based, educational program offering hundreds of topics including documentation.  

Remember, documentation is everyone’s responsibility and a proactive Quality Assurance Committee should be involved in auditing the documentation in medical records on a scheduled basis.  HealthCap recommends developing a plan to audit a specific number of records on a monthly basis.  The audit findings should be brought to the full Committee for a review and develop a plan to address deficient practices.  HealthCap Risk Management is available to assist your facility in auditing records, educating staff on documentation basics and developing a Quality Assurance program.  If you think your facility would benefit from this support, request this assistance when scheduling your next risk assessment visit or contact us at healthcapusa.com.