2.2.7: Confidentiality
Remember to always keep all information in the patient’s chart confidential. It is illegal to disclose information in the patient’s chart without their consent. their employer will provide them with specific training and information about the types of information they will require them to include in their site visit report.
| Sample Documentation |
| Date: 10/30/2014 |
| 0900 Assisted with feeding |
| 0930 Provided bed bath, oral care |
| 1000 Assisted with dressing |
|
1015 Changed bed linens, cleaned bedroom |
|
__1.5 hours____ Jennifer Noble, HHA Total visit time Signature & Title |
1. It is ok to use white out if you make a mistake documenting. ______
2. All documentation should end with a signed name, title, and include the date and time. ______
3. It is ok for a HHA/PCA to document that they gave the patient a bed bath before they actually did it. ______
4. It is a good idea to document a patient visit immediately after it is completed, before you moving on to the next patient. ______
5. Home Health Aides/Personal Care Aides should include subjective and objective information about the patient’s condition in their documentation, but never judgmental statements or personal opinions. ______
- Answer
-
1. False
2. True
3. False
4. True
5. True
Feedback :
1. Never use white out to fix an error. Patient charts are legal records. Draw a single line through it and put initials and date next to the error. Then, write in the correct information.
2. When documentation is complete, Home Health Aides/Personal Care Aides should sign it with their full name and title.
3. Documenting care prior to performing it is considered to be falsifying records.
4. Due to the difficulty in keeping track of observations made, care should always be documented immediately after performing it.
5. Judgmental statements or personal opinion should never be included in the patient care record. Objective observations, those that can be observed or measured and subjective information, symptoms the patient reports are types of information that should be included within the HHA/PCA’s documentation.
Communicating on the Telephone
Home Health Aides/Personal Care Aides will often use the telephone to communicate with their supervisor and other health care team members. Before making a call, they should plan out what they need to say and if they have a question, think about how they want to ask it. This will help them to keep their phone call to the point to avoid wasting time. It will also help to keep them focused on the purpose of their call. They will also be less likely to forget details that they may have wanted to include during the phone conversation.
When making a call, Home Health Aides/Personal Care Aides should identify themselves and then ask to speak to the person whom they are calling. If the person they need to speak with is unavailable, Home Health Aides/Personal Care Aides should leave a brief message with their name, the phone number where and until what time they can be reached. Do not leave a very detailed message. Leave only as much information as is necessary so that the person knows what they are calling about. Do not leave detailed confidential medical/health information on a message.
Sample phone call (adapted from Leahy, Fuzy & Grafe, 2013)
–Hello, Ms. Lopez, this is Anna Price. I am calling from Mr. Davis’s house. His daughter has a question about whether or not he can have tomato juice on his low sodium diet.
–Ok, so he can have tomato juice if it is the low sodium kind?
–Ok, I will let Mr. Davis’s daughter know this. I will write in my visit notes that you told me to tell Mr. Davis’s daughter that he can have tomato juice if it is labeled low sodium.
–Thank you for your help Ms. Lopez. Goodbye.
Sample phone message (adapted from Leahy, Fuzy & Grafe, 2013)
–Hello, Mrs. Mason , this is Karen Smith. I am a home health aide working with Mr. Chin. The telephone number here is 764-5297. I can be reached at that number until 2:00 pm.
–I am calling because Mr. Chin has a question about his breathing treatments. He would like to know how many times a day he can use his inhaler.
–Thank you very much. Goodbye.