Policy Manual sample

MDT Home Health Care Agency, Inc. POLICY ON CLINICAL NOTES/INITIAL ASSESSMENT It is the policy of this agency that the following rules shall govern all nurses' notes: 1.The initial evaluation/assessment (including OASIS assessment if applicable), to be done within forty eight (48) hours of the acceptance of a case. Paper/electronic assessment must be initiated as soon as possible, but in any case, no later than seventy two (72) hours from the time the case is accepted by this agency. Can be completed within 5 days. 2. All progress' notes (RN's, LPN's, Therapist’s) shall be due in the office (paper or electronic) no later than 1 week (second calendar day, before Tuesday 5:00 pm) from the time those notes were compiled. However, notwithstanding the provisions of this section, nurses' notes shall be turned in to the office, or web base software, no later than ninety (90) hours from the time they were written if the case constitutes a medical emergency or medical necessity. 3. Home Health Aides' notes shall be turned/completed electronically in to the office every 1 week (second calendar day before 5:00 pm) 4. All nurses (skilled and non-skilled) are required to make scheduled visits to patients as prescribed in the Plan of Treatment established for that patient. Notes on appropriate forms shall be made during the visits or as soon thereafter as possible but, in any case, not later than twenty four (24) hours after the visit is completed. Home Health Agency - - Skilled Professional Services C-5