Policy Manual sample

MDT Home Health Care Agency, Inc. PROCEDURE FOR WOUND/DECUBITUS SUMMARIES Purpose: Document and informs Clinical Manager/DON and patient’s physician of patient Wound/Decubitus status, progress, deterioration within the previous week of services. Definition: A summary which documents patients Wound/Decubitus condition/status within the previous 1 week services. Summary needs to be done in our Wound Record Summary Form in weekly basis. Procedures: I. Upon patient's admission for Wound/Decubitus Care, Q.A./field clinical personnel will provide the physician with a summary of patient Wound/Decubitus status. II. Upon completion of each week of services, routing will occur as follows: KEY POINTS: A. Field Nurse hand/electronic write the wound care summary directly in the appropriate Wound Care record summary form. 1) Do not include orders in the summary, they are already on POC and/or Verbal-Modify Orders. 2) Summary should always be attached to the regular nurse clinical notes of each week. 3) Wound Care must include last measurement, progression/deterioration, (size, odor, drainage, etc), treatment given provided, and must be drawn in the body chart. (Contain assessments relevant to care including documentation of an assessment of the wound bed or wound measurements). B. Returned to Clinical Manager/DON or QAPI personnel for proofing and discussion of Patient wound care progress or deterioration. C. Signed by field employee. D. Given to Medical Record for logging and failing. E. The document will be couriered, faxed or mailed to corresponding M.D. as his/her request, following HIPAA guidelines for confidential of Patient’s records. It is the Policy of our Agency that, with the authorization of Patient, or Patient’s Guardian, we may take Wound/Decubitus pictures to help document the Progression/Deterioration in our Wound Care Treatment Program, with the following procedures: 1- Ask Patient Permission to take the Picture. If the Patient has an authorized Guardian, request the permit to that person. 2- Fill out the PATIENT RELEASE TO PHOTOGRAPH Form (may be included in the Service Agreement form). 3- Always follow HIPAA Guidelines for Patient’s Privacy Rights rule. 4- Ask Patient or Patient Guardian to sign the Form. 5- Sign your self/employee, as witness. 6- Return the Original to Agency, for filling in Patient’s Clinical Record Chart. 7- Leave the yellow copy at Patient’s Home Chart, for his/her records. 8- A photography may be taken as documentation may indicate the need of more detailed explanation, in any improvement or deterioration of the wound occur, with not specific frequency, according our professional staff expertise or Physician order/request. If the Patient refuse to sign the Photograph Authorization Form, we support his desire and we will not take any Picture of him/her. Please document in the Form the Patient’s request, and return the original to the Agency’s office. Home Health Agency Nursing Care & Procedures K-106