Documentation Over-Kill

Documentation is a part of residential care. Sound documentation noting change in condition, action taken, and response is part of being a great provider. However, from time to time, we can create our own headaches by an overly demanding documentation policy. Often times I find people new to residential care may think they are a “better provider” because they require copious documentation.

As an industry, residential care generally performs “documentation to the exception.” In other words, when the resident is doing fine and all is status quo, we do not document. However, if there is a change, then documentation will occur. Should you wish to have elaborate documentation requirements, be sure they are realistic. Will you really follow the protocol? Will you really document that much every time?

Below are some types of documentation you may want to think twice about before implementing.

Percentage of food consumed

There may be rare occasions a physician may ask for a food consumption record; however, it is not the “norm” for residential care. There are two areas of concern with food consumption records. The first area of concern is lack of standardization. Try this test yourself. Show a partially eaten plate of food to several staff members. Now ask them what percentage of food was consumed? You may be surprised to see the answers will very significantly. The other major concern is follow-through documentation. IF you document poor food intake, be sure to document the action taken. Did you offer alternative foods? Did you notify the MD if it is a trend? Were there orders? Documenting poor nutritional intake with no follow-through makes the community look incompetent.

Is there an alternative to percentage of food consumed? Yes, regular weights.

Resident Checks

Some communities require staff to sign they checked the resident every hour or even more often. While at first glance this may seem like a good idea to ensure checks are really happening; however, take a real look at how these sign-offs are taking place. All too often they are not being signed every hour. Rather staff signs at the end of the shift over and over again. Think about it! Even in a six bed community, the caregiver would have to sign 48 times in an 8 hour shift. Is that really what you want your staff doing? Signing or providing care?

Often times, upon audits, I have found staff have signed on residents that were out of the building on a visit, hospitalized residents, etc. Perhaps the most egregious example is a residential community that had a resident elope. Upon subpoenaing the records of the community, it was discovered that the staff had signed that checks were being performed while the resident lay outside going hypothermic.

Good charting is absolutely necessary. However, more charting does not always mean better charting.

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