AUGUST 2019 EDUCATION

LEGAL DOCUMENTS


ALL CAREGIVERS MUST COMPLETE THIS EDUCATION AS IT INCLUDES REGULATORY CHANGES BY THE STATE, IF CAREGIVER DOES NOT UNDERSTAND ANY OF THE MATERIAL THEY SHOULD REACH OUT TO AMBER FOR FURTHER EXPLANATION!

As a personal care attendant, you are required to document the tasks you perform for you client as well as adhere to the tasks set forth by the patient's care plan. Documents are used by the entire care team to access the patient's needs and health status, which makes your role a very important one. There are several legal documents that are used in client care, two documents important for your role are the medical record and the care plan.The medical record is a legal document and its contents are confidential. The care plan is a document that is kept in the client's home and is used by all health care members. The medical record is also the timesheet you complete that shows what tasks were completed while you were providing care; the medical record should reflect the tasks that are required in the patient's care plan. For example in Mr Jones care plan it states that he requires a bed bath q every other day; this means every other day the caregiver should be completing a bed bath. If the caregiver works with Mr Jones every M/W/F these would be the days that the bed bath would be completed and documented.

Following the care plan instructions exactly provides a consistent standard for each task. Follow the instructions you are given even if they are different from the way you are used to doing a task, as new ways for common tasks may better serve the client’s needs. Using the care plan and following its instructions protects the PCA from liability. Liability refers to legal responsibility for things that go wrong while you are on the job. These include negligence, theft, abuse, and invasion of privacy. When the PCA follows the care plan and documents their care appropriately they are protected against a charge of negligence.

Remember never document a task prior to performing the task, and never document more or less than is required by the care plan. Provide accurate reporting and documentation. Failure to report accurately can lead to charges of negligence.A patient can not receive caregiving services by the agency while hospitalized, there is NO EXCEPTION to this rule.

New requirements require caregivers to document client status during visit on each timesheet/medical record. This documentation should be completed on the line that reads other: The caregiver should write in “client status” on the other line. The caregiver will document “at baseline” if the client is their normal based on their disease/ developmental level. For example Bridgette takes care of Mr Jones who had a stroke two years ago, Mr Jones is now wheelchair bound with slurred speech, has seizures and difficulty swallowing. This is Mr Jones’ normal so when Bridgette documents she puts “at baseline” for his status. However on Wednesday at 230pm while caring for Mr Jones he fell from his wheelchair onto his knees, with no need for medical intervention. Bridgette would help Mr Jones to his chair, check to ensure there is no need for medical intervention and report the fall to the agency. In her documentation of client status, she would write in the box *see note. At the bottom of her timesheet she would write *2/20/2019 Wednesday 230pm Mr Jones fell from his wheelchair onto his knees, patient reports no pain afterwards, no visible damage seen. Pt helped into wheelchair and made comfortable; fall reported to the agency at 240pm complaint taken by Denise.

Client status should always read “at baseline” unless something abnormal occurs during the visit or the patient is not their normal self.  

Documentation of client status describes your observations and becomes a part of the client's legal record. Good documentation should be factual, descriptive, brief, neat, easy to read and understand. What you document should be medically important and useful information. It is important to document accurately because should a problem arise, documentation may be used in the court as evidence. Remember as a caregiver you spend more time with the client than other members of the care team and therefore are more likely to notice daily changes in your client's condition. Other team members use your documentation for vital information to make decisions about the client's care.

Guidelines when documenting:
Use a black ballpoint pen
If you make a mistake, mark a single line through the word and write your initials next to the line
Do not leave any open spaces
Use appropriate abbreviations
Use proper spelling and language.
Make sure the client's name is on each page of the chart.
Never document before you complete a task.
Document immediately after a visit so you can remember important points.
Sign each entry with the date, your name and title.

It is important that the caregiver understand occurrences that must be reported to the agency immediately, these include the following:

Falls
Any New Wounds/Reddened Areas  
Seizures (that are not part of the patient’s normal functioning level)
Hospitalization
Any New Diagnosis or Medication

Although this article addresses documentation, the care plan and the medical record; remember you may be required to use other legal documents in your care. Always use your best judgement when completing legal documentation, and if you are unsure contact your supervisor for more instruction.