Policy Manual sample

MDT Home Health Care Agency, Inc. DOCUMENTATION GUIDELINES Document the following on the visit report: · Suspected or self-reported domestic violence · Patient referral and follow-up evaluation · Physician notification, if applicable · Any other pertinent findings When documenting injuries, precisely describe the appearance of the injury, noting size, location, color, and any other distinguishing feature. Using quotation marks, document verbatim quotes from the patient when she explains the cause of her injuries. Complete an incident report, if required. Update the plan of care, noting on each visit any new injuries or statement regarding abuse. L-54 Home Health Agency Client Assessments