LNCtips.com: Organizing Home Health Medical Records
Most home health records are now in electronic format. The easiest way to organize electronic records is to leave them in order. In other words, no organization is necessary.
With paper medical records, legal nurse consultants will find that Home Health records have some categories, such as OASIS assessments, that other organizations don't have. As with all medical records, Home Health charts are organized first by category and then in chronological order. LNCs can use the categories below to organize Home Health records or modify the order to fit individual preferences.
Administration
Plan of Treatment
Physician Orders
OASIS Assessments, including discharge OASIS with progress summary
Supervisory Visits
Clinical Notes
Notes from Other Disciplines
Labs / X-Rays / EKGs / Other Tests
...Katy Jones© All Copyrights Reserved 2011. LNCtips.com