Daily Documentation of Services Provided
Requires every caregiver and nurse to record, for every visit, the services actually performed for the client that day, with times, tasks done or not done and why, and any change or problem observed, so that the record is complete, true and incorporated into the client file.
About this policy
- Policy number
- GA-HC-RM-02
- Version
- 1.0
- Main rule
- Ga. Comp. R. & Regs. 111-8-65-.10(3)
- Library
- Georgia home care · 49 policies
- Category
- Records
- Sections
- 16
In short
- Record every visit: your real arrival and departure times, or check in and out on the EVV app.
- Mark each task you actually did, as you do it. Never fill in a task or visit in advance.
- If a task was not done, write why. Tell the office if the client refuses an important task twice in a row.
- Write down any change you notice in the client, and call the office at once if it needs action now.
- Ask the client to sign or initial the record, sign it yourself, and return paper records to the office every week.
What's inside
16 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (Ga. Comp. R. & Regs. 111-8-65-.10(3))
- 5. What Every Daily Record Shows
- 6. Procedure at Each Visit
- 7. Nursing Documentation
- 8. Review by the Supervisor and the Office
- 9. Responsibilities
- 10. Records and Compliance Monitoring
- 11. Staff Training
- 12. References
- 13. Related Policies and Forms
- 14. Approval
- 15. Revision History
An inspector may ask
- Show me how a caregiver records the tasks performed at each visit.
- How does the record show a task in the service plan that was not done, and why?
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