You need Java to see this applet.
DEBBIE HOMMEL'S AD TIPS
Dedicated to helping Activity Professionals with the daily operation of their department.
by Debbie Hommel, BA, CRA, ACC, Executive Director of DH Special Services.
The Activity Director's Office
Let Debbie answer your
Activity Questions
Visit
DEAR DEBBIE:
Documentation:
What's the Point?
By Debbie Hommel, ACC

The process of documentation can be a stress provoking process for many activity
professionals. We know it is important, but who has the time?  Entering information about
the resident or client is a responsibility many professional caregivers share. It is also a
privilege to be a part of the team, which is involved in assessing the resident, or client's
needs and developing treatment plans to provide appropriate care and services.  
Knowing this is important for anyone involved in the documentation process. Knowing
why we document - is the first step.

Communication: It would be wonderful if we could sit down with all involved
professionals and discuss resident/client care at length, on a daily basis. However, that's
not possible in most cases. The medical record can be a communication link between
professionals. This is a major reason why all entries should be accurate, timely and
written in a professional manner.

Justification: Although the profession is guided by standards of practice, each
resident/client is an individual. Sometimes interventions work and other times they do
not. Documentation, which chronicles interventions offered, and resident/client response
provide the department with justification as to why the current plan of care is in place.
Continuity of Care: Our main goal in caring for our residents/clients is to ensure quality
care and services. In some cases, multiple staff cares for the resident/client within a
department. Documenting pertinent information, treatment plans and response to care
can act as a guide for staff to follow. This prevents repeating unsuccessful efforts,
maintains successful approaches and permanently records individualized information the
resident/client provides upon admission.

Accountability: "If it isn't documented, it isn't done!" is a common response as to why
documentation is important. There are regulatory requirements defining certain entries,
which is what this common perception is based upon.

What guides the documentation process?
Who makes the "rules"?

There are two supporting factors, which define and direct required entries.
Legal Factors: Regulations! Health care settings are defined through and State
regulations. The activity professional should become familiar with the regulatory
agencies that govern their facility. The regulations will clearly define which entries are
required, time frames for completion and in some cases, actual content.
Professional Factors: Each profession is guided by Standards of Practice. The
established professional organizations (National Association of Activity Professionals, to
name one) have written Standards of Practice. They clearly define documentation
standards and content. Being affiliated with a professional organization provides access
to this information, which can further guide the professional in appropriate
documentation content.

General Medical Record Guidelines

  • Sign all entries with full name, job title, and date.
  • Never use white out.
  • When an error is made, cross it out with one line, write "error" and initial & date.
  • Use only approved medical abbreviations.
  • Write legibly; and ensure spelling and grammar is correct.
  • Use black ball point pen.
  • Do not skip lines. If open lines are left,
  • they need to be crossed out before the next entry.
  • Be accurate, concise and factual.
  • Stay away from generalized judgments which are vague.
  • Be aware of facility policy regarding medical record
  • guidelines, use of forms and individual entries.
About Debbie

Debbie Hommel, BA, CRA, ACC, is
the Executive Director of DH Special
Services. She is a Certified Activity
Consultant on State and National
level, with over twenty-seven years of
experience in providing direct care
and consultation to long term care,
medical day care, assisted living,
and ICF/MR facilities throughout New
Jersey, New York, Maryland, and
Pennsylvania. She is an experienced
trainer and workshop presenter,
conducting a variety of seminars
throughout the Tri-State area for the
Activity Professional, Administrator,
and allied healthcare professional.
Debbie Hommel is an active member
of Activity Professional Associations
on State and National levels. She is
ACC certified through the NCCAP.
She is a founding member of the
New Jersey Activity Professionals'
Association, serving terms as Vice
President and President. She
received the Weidner Lifetime
Achievement Award in 1994 and the
Monmouth & Ocean County Activity
Professionals Life Achievement
Award in 1999.
THE ACTIVITY DIRECTOR'S OFFICE
Providing Internet Resources
for Activity Professionals
in Long Term Care Settings
admin@theactivitydirectorsoffice.com

Copyright 2004-Present
The Activity Director's Office
All Rights Reserved

Disclaimer
ACTIVITY DIRECTOR TODAY
E-MAGAZINE
Subscribe Today
(Just $24 per year)
BACK      HOME