Q: My agency requires that we complete our charting while in the patient's home. Why do I have to chart in the home? There is so much to do, and it is much easier to just take a few notes and wait until I am home or back in the office in the afternoon to do my charting.
There are several reasons why charting in the home is important. The first reason is the clinical record, which includes the home visit note, is a legal document, which must demonstrate that the care that was provided for the patient was based on a comprehensive and appropriate assessment, is clinically sound based on the assessment, and meets the criteria for payment. In cases of litigation the clinical note can be reviewed years after the visit to "refresh the memory of a witness who must offer testimony about the care provided [,] ... consulted to discover the facts pertaining to a claim of poor patient care[,] ... examined by an expert witness who must render an opinion on issues essential to litigation claims" (Connaway, 1985, p. 6). If a clinician is going to be held accountable for his or her care many years after the care was provided, it behooves the clinician to ensure the documentation clearly supports the assessment performed and the care provided to the patient.
Secondly, as clinicians are assessing patients, they are learning about the patient and making connections that lead to interventions. Studies have shown that people, on average, forget what they have learned very rapidly after learning it, with variations of forgetting 0% to 73% of what was learned within 1 to 2 days (Thalheimer, 2010). Additionally, memory is affected by lack of sleep and stress, two common issues in our society today. It is easy to assume that you will remember what happened during the visit by taking a few notes, or because the care was "routine," but there is nothing routine about the assessment or care provided in the home to an individual patient. Notes jotted down quickly do not generally translate to documentation that is specific, measurable, and clearly delineates the skilled intervention provided. Also, as multiple patients are seen in a typical workday, it is easy to confuse assessment data by the time you return home or to the office. Documenting as the care is being provided decreases the potential for errors in clinical assessment or interventions.
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