Question

You will hear about documentation constantly in the health field. Everything you do with a patient must be documented. If its not documented, you have no proof that you did something. Proper documentation is also required for reimbursement.

1. Long term care facilities require 4 areas of documentation, what are they?

Answer 1

Long term care facilities require four areas of documentation: medical history, assessment and care plans, progress notes, and incident reports.

Step-by-step explanation:

Long term care facilities require four areas of documentation:

1. Medical History: This includes information about the patient's past illnesses, surgeries, and medications.
2. Assessment and Care Plans: This includes the patient's current condition, diagnosis, and the care plan that outlines the steps to be taken.
3. Progress Notes: These are written by healthcare providers to document the patient's progress, any changes in their condition, and the treatments provided.
4. Incident Reports: These are filled out when any unexpected events or accidents occur, such as falls or medication errors.

These four areas of documentation are critical in ensuring the quality of care provided, maintaining patient safety, and supporting reimbursement for the services provided.