Policy Manual sample

MDT Home Health Care Agency, Inc. CASE MANAGEMENT NOTES POLICY Home Health Care Registered Nurses provide documentation regarding care coordination, management of service to clients. PURPOSES 1.To ensure a continuous flow of information during the services period. 2.To provide a clear picture of the services being rendered. 3.To described administrative and clinical problems and issues, and their outcome. 4.To provide a documented source of information of events. 5.To elicit a degree of accountability for all parties involved. 6.To incorporate a plan of action and/or follow-up scheme. 7.To prevent loss of information during transitional periods. 8.To serve as a backup for actions taken. 9.To assist in simplifying the auditing process for internal and external governing bodies. 10.To document information such as telephones call conversations and messages received and initiated. PROCEDURES 1. The Case Management Notes are to be utilized mainly by the Nursing Department. The Director of Nursing, Clinical Manager and/or Nursing Supervisor will utilize Case Management/Coordination Notes from the first day of the referrals and continue through discharge. The information reported by the field staff to the Agency may be in writing or by phone. 2. The Case Management Notes will contain actions, significant finding and conversations transpired during the service period. 3. The Case Management Notes will adjunct “Visit Clinical notes.’’ 4. The Case Management Notes should include the following: a. Date and time b. Reason for the note (significant finding who facilitate coordination of care) c. Who was contacted/or contacted the agency? d. Why was there contact? e. What was discussed? f. What actions were taken? g. Outcomes of the discussion/or action taken. h. Plan of follow-up action I or relay of information to be done. i. Signature of staff making a report. 5. Case Management Notes will be placed in the client’s clinical file in reverse chronological order, with the most recent note on top. L-11 Home Health Agency Client Assessments