Documentation in the Home Healthcare Setting - Documenting and Reporting

Question 1

The focus in ___ health care is on family-centred care and forming a partnership or collaboration with the patient and the family to help the patient regain health, to help the family take over the patient’s care, or to help accomplish both.

Answer 1

home

Question 2

Documentation in the home health care system has different implications than in other areas of nursing. Two primary differences are that the majority of the care is performed by the patient and family and that the nurse is often t___ and helping the patient and family achieve greater independence. Nurses must have astute assessment skills to gather the needed information about ___ in the patient’s healthcare status. In addition, documentation systems need to provide the entire healthcare team with the information needed for them to work together effectively.

Answer 2

t-eaching /changes

Question 3

The usual forms used to document ___ care include the following:

• Assessment forms
• Referral source information or intake form
• Discipline-specific care plans
• Physician’s plan of treatment
• Professional order form (e.g., MD, speech-language pathologist, specialty nurses)
• Medication administration record
• Clinical progress notes
• Miscellaneous (case conference notes, professional communication forms, private billing forms, insurance company forms)
• Discharge summary

Answer 3

home

Question 4

In the home care setting, the patient is the gu___ of the healthcare record. A hard copy of the healthcare record is kept in the patient’s ___, and the patient is re___ for its safekeeping.

Answer 4

gu-ardian / home / re-sponsible

Question 5

Communication is crucial in h___ care because much of the interaction between healthcare providers is conducted virtually by phone or fax over password-protected voice mail or secure fax lines.

Answer 5

h-ome

Question 6

With the increasing availability of smart phones and laptop computers or tablets, home health care records can be available in multiple l___, improving accessibility to information and facilitating interprofessional collaboration.

Answer 6

l-ocations