Rules, Man
If you don't do this, it's like it never happened.
What is document it?
This needs to happen immediately after service provision.
What is service documentation?
This shows how people direct their own lives and select the things they want
What is offering choices?
What is by by the person who wrote the doc or had first hand knowledge?
Types of things like date of birth, full face photo, social security number, Medicaid ID number.
What is PHI or Protected Health Information?
4 Items that Medicaid says every narrative entry should include
What is the date, time, location, and signature/title?
These are the type of reminders you give the person you supporting
What are prompts?
The best way to refer to other employees in your documentation
What is as "staff" or by their title (QAC, CC, etc.)
This is how you make additions to your doc DURING your shift.
What is use the "edit entries" button?
This is the idea that not everyone needs access to everything.
What is Minimum Necessary?
Two things you must document when you take an outing
What is the location and time?
This is the way you should describe your services; not using your opinions.
What is the observed facts?
What is the exact location of service?
This is how you make additions to your doc AFTER your shift.
What is do an "Add to Daily Log"
This unique set of letters and numbers you use should NEVER be shared with others.
What is a password?
These are what require us to maintain records to disclose our services and support claims billed.
What are State and Federal laws?
Staff should check this before using an abbreviation
What is the Approved Abbreviations list?
A good way to judge if you have this right is by asking yourself how much would you pay for this.
What is having enough good content or "meat" in your narrative?
This is what you do if you have a major "oops" when documenting.
What is call Karla, Erin S., Care Coordinator, etc.?
This is what you should do if you need to step away from the computer while Edoc-ing.
What is sign out and/or close the laptop lid?
What is the name, dosage, and route of administration?
Two things to put in every sentence that shows how you helped someone and what happened after that.
What is staff action and consumer response?
A good way to check this is to ask yourself, "How would I feel if this was written about me?"
What is be respectful in your documentation?
What is on your next scheduled shift?
This is what you should do if someone you don't know wants to see a person's doc or file.
What is ask for identification, and/or contact a supervisor?