Mahler C L
Visiting Home-maker Service of Hudson County, Inc., Jersey City, NJ, USA.
Home Care Provid. 2001 Aug;6(4):120-5. doi: 10.1067/mhc.2001.117492.
Although most health care professionals would wish it otherwise, documentation will never be eliminated completely. It can be ignored and complained about, but documentation will always be there to remind us, "If it wasn't documented, it wasn't done." Home care providers need to be cognizant of the imperative for effective documentation. Corporate compliance initiatives, fraud and abuse issues, and changes in reimbursement mechanisms make documentation more important than ever. Home care providers must create an environment conducive to effective documentation practices.
尽管大多数医疗保健专业人员都不希望如此,但文件记录永远无法完全消除。它可能会被忽视和抱怨,但文件记录总会在那里提醒我们:“如果没有记录,就没有做过。”家庭护理提供者需要认识到有效记录的必要性。企业合规举措、欺诈和滥用问题以及报销机制的变化使得文件记录比以往任何时候都更加重要。家庭护理提供者必须营造一个有利于有效记录做法的环境。