tips for reporting
What Should I Include in the "Summary" Section?
- Documentation should record facts, such as your observations and actions during the visit.
- Include details about how the patient looked, behaved and their responses. Note the patient’s comfort level, physical appearance and behavior.
- Record what the patient or family said, using quotations or paraphrasing.
- Avoid giving your opinion about the patient’s health.
- If the patient was uncomfortable, document what actions you took to address their discomfort.
- If you interacted with our team members about the patient or family, please include that information, as well.
- Please remember that your notes are considered official medical records and are reviewed by members of the patient’s care team. In some cases, this includes the patients and their families.
What are some issues that should be reported immediately?
- Medical emergencies: Any sudden deterioration in the patient’s health condition, signs of a stroke, heart attack, severe respiratory distress or any other life-threatening situation
- Fall or injury
- Equipment failure: Malfunction or failure of medical equipment essential for patient care, such as oxygen concentrators or hospital beds
- Signs of abuse or neglect
- Family or caregiver distress: Situations where family members or caregivers are experiencing extreme stress, emotional breakdowns, or expressing an inability to cope with the patient’s condition
