QAPI Program Utilization_Manual

POLICY ON PATIENT'S CLINICAL NOTE S POLICY: It is the policy of our Agency that weekly Clinical notes shall be written on each of our patients, preferably each Friday. Such a Clinical Note, to be written on our standard "Clinical notes form" paper or electronic form, shall be written by a Skilled Nurse/RPT/HHA/ CNA/OT/MSW/ST staff, who also should supervise the case in review, together with Supervisor RN/RPT Staff. Completed clinical notes, along with other pertinent patient records, shall be submitted to the Director of Nursing, Clinical Manager (at the office), or electronic completed once every two weeks (by the second business day, before Tuesday 5:00 pm). (All notes belonging to the previous work week, from Sunday thru Saturday) Home health care staff members will ensure complete concise documentation of services, issues and conditions occurring during the period of services rendered to the client. The full time spend in the patient’s place of residence, while providing services to the patient, must be recording in the corresponded form, from the beginning of the visit that included setup of the work area, bag technique, professional handwashing/hand hygiene technique, adequate gloves changes, and the application of treatment order and procedures. UNIT KEY: 1 unit = 1 minute to <23 minutes 2 units= >23 minutes to <38 minutes 3 units= >38 minutes to <53 minutes 4 units= >53 minutes to <68 minutes 5 units= >68 minutes to <83 minutes 6 units= >83 minutes to <98 minutes 7 units= >98 minutes to <113minutes 8 units=> 113minutes to <128minutes It is our Policy that we allow the use of automatic mechanism to help our staff to complete their Clinical notes report like typing by Typewriter, Word Processor, or Computer Software, in compliance with the following steps: 1- Ensure the compliance of HIPAA regulations and guidelines, including the care of the Patient’s Privacy Rights 2- Don’t allow any other person access to any Patient Information needed to complete the work. 3- Destroy all Patient Information after completing the Clinical notes 4- Inform immediately to the Agency’s Privacy Officer if any breach of HIPAA guidelines for Patient’s Privacy Rights is suspected. 5- In the use of Computer Software or any electronic device to help complete the progress note, the staff can not save any Patient Information in the Staff Personal Computer/tablet,is the patient’s information is used, the Staf must delete that information, immediately after completing their work. Wound Care record must include full description of the procedure/order done and treatment provided, and at least weekly measurement, progression/deterioration, (size, odor, drainage, etc), all to be documented on a weekly summary. Report MD any significant change in condition. 29