Service Documentation and Accurate Records
Sets how direct care staff and supervisors document every visit, what a visit record shows, how entries are corrected and late entries made, how records are turned in and reviewed before billing, and the Florida prohibitions on fraudulent records (charting ahead, recording what was not personally observed, borrowing records, falsifying signatures), with the fines a licensed agency faces for patterns of false records, billing for services not provided, and failing to provide agreed services.
About this policy
- Policy number
- FL-HC-RM-02
- Version
- 1.0
- Main rule
- s. 400.474(2)(d), F.S.
- Library
- Florida home care · 50 policies
- Category
- Records
- Sections
- 18
In short
- Fill in the visit record during the visit and finish it before you leave the home.
- Write only what you did and saw yourself, at the time it happened. Never fill anything in ahead of time.
- Write your real arrival and departure times, not the scheduled times.
- Never sign for anyone else, and never ask a client to sign a blank record or several days at once.
- To fix a mistake, draw one line through it, write the correct entry, the date and your initials. Never erase or use correction fluid.
- Turn in paper visit records at least once a week.
What's inside
18 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (s. 400.474(2)(d), F.S.)
- 5. Who Documents What
- 6. What Every Visit Record Shows
- 7. Accurate Records: What Is Never Allowed
- 8. Timing, Corrections, and Late Entries
- 9. Turning In and Reviewing Records
- 10. Plain and Useful Records
- 11. Responsibilities
- 12. Records and Compliance Monitoring
- 13. Staff Training
- 14. References
- 15. Related Policies and Forms
- 16. Approval
- 17. Revision History
An inspector may ask
- Show me the visit records for this client for last month. Do they match the schedule and the bills?
- How do you know your staff did not complete these records ahead of time?
See Cura Core with your agency's name on it.
Choose your state and type of agency, buy your Policy Pack online and get your sign-in by email. Already a customer? Sign in to your portal.