The RIGHT to WRITE
Put opinions in documenting about a client.
What is DON'T
The care notes are medical documents and opinions are not allowed. You may put what facts you observe but not your opinions.
Wait to clock out until you are finished documenting 30 minutes after your shift should have ended.
What is DON'T
Proper documenting should take 5 to 10 minutes and should be done prior to the end time of your visit. Just let the client know what you are doing.
Call the office to report a clients change in condition or situation.
What is DO
No matter who makes the change, (other home care, family or client) let the office know the same day or next business day if not urgent.
IMMEDIATELY report new, renewed or expired car insurance to the office.
What is DO
AS SOON as your insurance expired you are REQUIRED to provide updated information to the office via email. Failure to do so could result in being pulled off of your shifts.
Always respond to open shift requests.
What is DO
Whether you can do the shift or not, it is a good idea to respond so the office knows you are not able to do that shift and can continue trying to staff it.
Address boundary crossings when they occur by calling the office.
What is DO
We want you and the client to be comfortable with the visits. If a line is crossed, please immediately call the office to discuss it and find a solution.
Write facts and services performed straight forward and to the point.
What is DO
Care notes are not the place for long stories. The family can read these. Care notes should be simple and factual only.
Clock-in to your shift in your car and quickly go into the clients and begin the visit.
What is DO
This is the best practice to avoid forgetting to clock-in. "Clock-IN, GO-IN"
Call the office to talk about a client you saw earlier today while you are currently with a different client.
What is DON'T
This not only takes time away from the client you are currently visiting, but also puts you on the phone when not needed AND could violate HIPAA.
Record mileage from your home to client's house and any errands done in client's car.
What is DON'T
Mileage is not paid to get to and from work unless over 20 miles on a case-by-case basis.
Any errands in client's car is also not paid for mileage as you did not use your gas.
Keep a change in your availability to yourself.
What is DON'T
You are given shifts and hours based on what you last told us you can work. If you want more hours than you have to be more available.
Tell another agency how you think the client should be cared for.
What is DON'T
Hospice or facilities will ask if they want to know what you think. Outside of them asking talk with the office if you have a concern regarding client care.
Always record a refusal of any task or notate an incomplete task in some way.
What is DO
If the client is refusing to shower or eat or do several of your tasks it is important to notate and let the office know if it is a consistent problem.
Never leave an incomplete task blank. This ensures the office and family the client is getting the care they need. It also is used for billing with Long term care.
Plan ahead of time to be 10 minutes late to your clients and stay 10 minutes later to even the time out.
What is DON'T
If you are going to be late you need to let the office know. Depending on the situation, you may lose the time you were late and could face consequences for it.
When talking with your friends or family you mention your client by name.
What is DON'T
Never mention the client's name, address or any personal information to anyone outside of the client's care. Doing so could result in a HIPAA violation.
Drive really fast with a client in the car and an expired drivers license.
What is DON'T
You never drive "really fast" with a client in the car, you want to obey the speed limits.
NEVER drive a client in ANY vehicle if your driver's license is expired!!!!
Text your friend while you are on a shift so you can meet them right after work.
What is DON'T
STAY OFF your phone on a shift unless documenting or communicating with the office.
This could also violate HIPAA.
Go ahead and give the client or family your personal cell phone number if they ask for it.
What is DON'T
Please instead provide the Home Instead office phone number and ask them to call us if they need to reach you.
Go on and on with a story that happened with the client about how she ran out of cat food and had to go find some and eventually was able to feed her cat.
What is DON'T
Long stories are fun to talk about sometimes but care notes is not the place for that. If something is very important and long call the office.
Wait for office/AOC to call YOU about your missed clock-ins or outs.
What is DON'T
If you miss a clock-in/out, immediately contact the office to notate the account. It is your responsibility to notify us so that you can get paid.
Door Dash yourself some lunch to the client's house.
What is DON'T
This would give out the client's address and is a clear violation of HIPAA and could cost your job and/or a hefty fine.
Respond via email to ALL communications regarding expired car insurance.
What is DO
The number of emails going out regarding expired insurance is INSANE! Please get those turned in immediately after Wellsky lets you know it is expired or due!!!
ALWAYS report a problem or concern to the office and not the client even if they ask.
What is DO
We all have problems. BUT the client's is not the place to talk about them. The office staff is very good at problem solving and is willing to listen as long as you don't unload them on the client. DO NOT tell client's personal problems.
Speak with the office about a conflict of interest for a side business or personal services you might like to help the client with.
What is DO
The client has a conflict of interest form you might be able to fill out to allow you to still provide other services to the client outside of Home Instead.
Use "I" and "Me" in charting and documenting.
What is DON'T
Using personal pronouns is not acceptable in medical documentation. Simple omit the pronoun. These are your care notes, we know YOU did them.
Discuss a time change in the shift scheduling with the client and not tell the office.
What is DON'T
Please do not talk with the clients about scheduling. If you or the client has a desire to adjust the schedule, contact the office or instruct the client to do so.
Get a ride to work from a friend because your car has a flat tire.
What is DON'T
This would give out the client's address and is a clear violation of HIPAA and could cost your job and/or a hefty fine.
Document every location you drove the client to during your shift.
This informs everyone (family member, office etc.) of where client is going and why they are being charged milage.
Respond to any communication from the office as quickly as possible.
What is DO
The office relies on your response to things. Whether it is a shift pick-up, a change in scheduling, a client update or even just a word of encouragement. We want to hear from you as soon as possible.
Take the client clothes or property home to wash or mend it if they ask you to.
What is DON'T
This puts both parties in a tough spot. It has the employee working without pay and puts them liable if property is damaged or lost. It also has the client frustrated with other caregivers who will not do they because they know they are not supposed to.