Home Health Aide On-the-Go In-Service Lessons: Vol. 6, Issue 9: Effective Documentation (Home Health Aide on-the-Go in-Service Lessons, Volume 6)

This lesson on Effective Documentation includes a complete training packet. Each in-service packet takes approximately one hour to complete and fully meets the Medicare in-service training requirements. As aides need training, you can make as many copies as you want - there s no restriction when used with aides assigned from your office location. Remember that Home Health Aides must have 12 hours of in-service training every year. LESSON OBJECTIVES Upon completion of this program, the home health aide will be able to: Understand the importance of accurately documenting patient care Describe his or her role in the documentation process Explain the relationship between documentation and the plan of care, and Document patient care clearly and according to regulations. OVERVIEW The patient s clinical record is the primary source of information regarding a patient s care. Caregivers and agencies use it as a record of the care the health care team provides. It is not only a home health aide s source of instruction, but it is also an aide s tool for documenting care provided. As such, it is important that aides know what documentation is required and the best way to describe that information. This in-service discusses the aide s role and documentation reasons, tips, and examples, and includes a short grammar review.