One of the biggest challenges within the home care industry today is an agency’s ability, or lack thereof, to compile a complete and accurate account of a client’s care experience. Documentation is vital as it shows that quality care has been provided. Good clinical documentation also:
- Offers Valuable Information to the Rest of the Client’s Health Care Team: Home care agencies play an important role in the health care continuum for their clients, and timely, accurate clinical documentation helps care team members from across the continuum provide better care.
- Improves Safety and Health Outcomes: Documenting client care allows for quick identification of emerging issues and potential problems so that they can be addressed proactively.
- Improves Care Plan Effectiveness: Documentation clearly shows the client’s diagnosis, that care that has been provided, and what is left to do.
Well-organized clinical documentation also protects your agency from potential risks and/or compliance audits, and it should include:
- The client’s care plan
- Assessments and clinical status
- Any problems or noted health issues
- Care goals
- Interventions and the client’s response
- Variances from medications, procedures, protocols, etc. and the action taken
- Communications with physicians and other care providers
- Any unusual occurrences or incidents
In order to accurately document the completion of ADLs for a client, agencies need to have an effective system in place. However, many home care agencies still rely on paper documentation, which is a time-consuming and ultimately inefficient process.
Home care software systems, like Arrow Solutions, are designed with efficiency and compliance in mind and can help agencies meet the needs of their clients, their clients’ extended care team, and Medicaid. Our web-based HIPAA-compliant clinical documentation portal allows caregivers to easily log in, fill out, and electronically sign clinical documentation forms, and, in cases where a form needs to be signed by multiple caregivers, the agency can have an RN complete the form, and then enable the patient’s physician to access that form through the portal, reducing the need to mail and/or fax forms back and forth and increasing efficiency all around.
Comprehensive home care documentation is necessary to ensure both quality patient care and proper reimbursement, and when documentation and processes/systems work, everyone benefits. Arrow’s clinical documentation portal can help agencies provide better care to their clients and better service to referral partners as well. Contact us today to learn more about our agency management and clinical documentation software.