9.23 : 장기 및 가정 의료 환경의 문서화

Let us understand the documentation process in long-term care facilities and home healthcare settings.

Documentation in long-term care promotes interprofessional patient assessment and planning.

In long-term care facilities, patients receive round-the-clock comprehensive care, including housing, meals, specialized nursing care, treatment services, and personal assistance.

Long-term care facilities use the Minimum Data Set or MDS and Care Area Assessment or CAA as valuable tools for documenting data.

These data forms are filled on admission and then periodically for all the patients in nursing homes.

Next, documentation in home healthcare includes patient assessment, referral, intake forms, and the interprofessional care plan.

These records can be accessed from multiple locations using laptops and computers, enabling interprofessional collaboration.

Nurses use the Outcome and Assessment Information Set or OASIS and the Omaha System to document clinical assessments and care provided in the home care settings.

OASIS is required for adult patients receiving skilled care through Medicare or Medicaid-funded home health agencies.

Meanwhile, the Omaha System is a research-based taxonomy that improves practice, documentation, and information management in home care.