Documenting Client Care

Accurate reporting and documentation of client care is crucial! If you provide care for clients without documenting thoroughly and carefully—your employer may not get reimbursed for your work. If you document care that you did not perform, your employer may not get reimbursed, and WILL POSSIBLY be fined for the false records.

YOU SHOULD DOCUMENT:

Your observations, the facts and events that you notice during your daily work.
Daily measurements like vital signs, weights, I/O, blood sugar.
Safety issues.
Client statements and/or complaints.
Unusual events like refusing care.

THE RULES OF GOOD DOCUMENTATION:

Make it complete.
Keep it consistent.
Keep it legible.
Make it accurate.
Finish on time.

SOME DO's AND DON'Ts OF DOCUMENTATION

Stick to the facts—because facts speak for themselves. (No one can argue with the facts, but they can argue with your opinions!)
Be specific! For example, it’s not very helpful to write “client ate well.” Writing something like “client ate 75% of lunch tray” is much better.
Avoid documenting the same information about a client day after day. Observe each client carefully and document even small changes.

Chart for someone else or write down what someone else tells you about a client.
Use two different colors of ink for the same entry. Someone might think you came back later to correct your initial charting.
Document your client care ahead of time—even if it never seems to change from day to day.

REMEMBER!

Your documentation may be read by:

Your coworkers and supervisors
Surveyors
Researchers
Quality Improvement personnel
Medicare and insurance reviewers
Lawyers and judges

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Last updated on August 5, 2022

Documenting Client Care

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