Policy Manual sample

MDT Home Health Care Agency, Inc. Documentation of the who, what, where, why, when, and how of care is the best evidence of competent nursing practice. "The credibility of the information in a medical record is very difficult to refute. Because of this, the medical record is the nurse's best defense in the event of a law suit" All employees must be aware of the consequences of violating the policies and procedures related to the computerized patient record. Staff must be aware of strategies to minimize risk in the use of the paperless record. Such strategies include the following: not altering patient information previously entered, correctly identifying late patient information entries as late entries, logging-off the computer when not currently in use to prevent others from viewing patient information, positioning computer screens to minimize viewing by those who do not have the need to see or know the information, reporting any incidence of unauthorized entry into the record, accessing only the information that the healthcare personnel need to know. Computerized documentation systems are like any other new technologies introduced into the healthcare environment. Staff must be adequately educated on the appropriate use and related ethical and legal issues. Staff competencies must be reviewed on a regular basis, and competency checks must be maintained. The paper record. We will provides the following guidance to nurses related to charting: write legibly, use ink, never erase an entry, provide the date and time for all entries, use a "late note" for matters charted out of sequence, and do not leave blank lines on the medical record The incident report. We encourage the use of an incident reporting system to document accidents and errors. Incident reports are an integral part of a risk management program and help risk managers track conditions that might need to be corrected. Incident reports can help those in staff development identify education and training needs. Incident reports assist the Director of Nursing, Clinical Manager and nurse managers in tracking and maintaining staff competencies. We urges that nurses/therapist know what must be reported, (such knowledge is a must for a Home Care's nurse employees and any contracted staff), complete the incident report in its entirety, be objective in reporting, include names of witnesses to the incident preserving the confidentiality of witness patients by using the patient's Medical Record number, submit the incident report through proper channels, never refer to incident reports in a patient's record as the privilege of confidentiality can be waived, consult with the Director of Nursing, Clinical Manager or the Administrator when questions arise. Home Health Agency Nursing Manual J-73