Documentation Review

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Documentation Review

  • MM slash DD slash YYYY
  • Clearcare App and Telephony:

    - Notate any refusals of care and any cares/tasks that were not performed. It will not let you answer “No” to a task without a reason. EX: Client refused, Client independent, Not needed today

    - Always leave a general comment after completing your tasks. It is required by Medicaid to document your observations during every shift even if the client has no refusals or changes in their health.

    -If there were no refusals or changes, just make a note of something you accomplished that day or the client’s mood/anything you observed

    - At the end of each shift, it is required that you get signatures for both you and your client. If you have a two-part shift, meaning your shift is broken up into two connected segments, you have the option put a line or X through the signature boxes of the first part of the shift.
    You are required to get signatures at the end of the second part of your shift. You also only need one detailed general comment per shift, even if it is divided into two segments.

    -If you have a two-part shift, you must clock out and back in between segments. If you are running errands with/for the client and are unable to clock out at the scheduled time:

    -Complete the task list and then call the office and have us clock you in and out between shifts
    -Wait until you are back at the client’s home and clock out then clock back in late, and call the office to have us adjust it to the scheduled time after the fact.
    -Please check that your clock out went through correctly! After you confirm your clock out your screen should turn bright orange and say “Good job, (your name)!” the shift will have a green line and the word “Completed” next to it on the home page.

    Paper Progress Notes (Must have agency permission):

    - As of September 1st, 2021, Medicaid no longer accepts paper progress notes as regular forms of documentation. Instead, they require the use of an EVV, or Electronic Visit Verification software.
    This means that our agency will be requiring all caregivers to use the Clearcare App or Telephony to document. Our agency will only accept paper progress notes if there is an issue with Clearcare and the caregiver has asked for or been given permission to use a progress note by an office staff member.

    - Mark an “X” next to each task performed, this would include cueing your client. Ex: asking your client if they have bathed, encouraging your client to eat nutritious foods or asking if they have taken their medication. Please refer to the care plan to know what is expected of you, and do not preform or document tasks that are not in the care plan.

    - Cares outlined in the clients care plan need to be performed at each shift. If you do not perform a care/task you need to notate why in narrative documentation.

    -Narrative Documentation Section must be filled out every day with dates next to corresponding documentation.

    - Notate any refusals of care and any tasks that were not performed and why. Ex: “6/1-Bath not needed today” or “6/2-Shopping is done Fridays”

    - Always note any changes to the client condition. Ex: “6/2-Client had a recent fall, has bruise on r. shin” or “6/6-client is having surgery on Friday.”

    -If there were no refusals or changes, just make a note of something you accomplished that day or the client’s mood/anything you observed.

    -Just like with Clearcare, the paper progress notes must be filled out daily. Take five minutes at the end of your shift to document tasks/cares performed, narrative documentation and capture signature from client.

    - Progress notes are due the Sunday of each pay week. Late progress notes may not be paid out until the following pay period.

    - If you notice a change in your client’s health condition and/or the plan of care is NOT reflecting his/her needs it is your responsibility to contact the office and inform us of the changes (208)-947-4020
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