Guest Guest_KateAA Report Share Posted June 19, 2006 STOP! You are asking for a deficiency! The medical chart is a legal document and subject to legal review. Placing the attendance sheets in it will cause you to have to explain it in a court of law. You have your assessment, progress notes, care plans and MDS..why would you put documentation in a chart that serves no purpose except to casue a surveyor to see that Mrs Smith only participates once a week becasue her family visits her everyday and she is perfectly happy with her TV and knitting???? Even your most active residents will have days that they are doing something that you haven't seen them do and didn't mark on your attendance sheets. Why cause a deficiency for yourself? Quote Link to comment Share on other sites More sharing options...
Stacy 0 Report Share Posted June 19, 2006 I agree with Kate. No way. I store them separately in a file cabinet. Our company requires us to keep them for 5 years. I don't know if that is federal law or their requirement on that. That may be the retention requirement. Stacy Quote Link to comment Share on other sites More sharing options...
Laree 0 Report Share Posted June 20, 2006 Hi! Help me out here, please! I was under the impression that attendance records HAD to go in charts. I keep 3 months worth in a binder that we document in. Then place all the past ones in resident charts. Surveyors have always asked to see my attendance binder. What is the difference where those records are? If I file them separately, or not in res' charts, they still want to see them. If I can avoid problems with this, let me know! THanks! Quote Link to comment Share on other sites More sharing options...
Pennie 26 Report Share Posted June 20, 2006 Hi.. Charts (medical charts/medical records) and Participation Records should be kept seperate. Normally Charts are kept at the nursing station, these contain physician orders, nurses orders, social worker notes, activity notes, initial assessment, progress notes, careplans, mds .. most everything in this chart should be signed by the certified professional that wrote them. The participation records should be kept in the activity dept. and should be updated as the activities occur, you should keep these updated and current. Keep 3 months of current records on each resident, in a binder and they should be ready to hand over to state surveyors when they enter your building (without them asking). All participation records past 3 months to 15 months should be filed in your activity office file cabinet or file boxes, and everything past 15 months should go the your facilities medical records area. hope this helps.. Pennie :-) Quote Link to comment Share on other sites More sharing options...
hcornell 0 Report Share Posted June 20, 2006 Pennie, I believe you meant the records for the charts should be signed by the qualified professional who wrote them, not certified. You do not have to be certified to write notes, etc. I agree with everyone. Do not put your attendance sheets in the charts. If your notes are current, they shouldn't need to see those anyways. I shred mine aftert survey, and start over. Quote Link to comment Share on other sites More sharing options...
Pennie 26 Report Share Posted June 20, 2006 Check with your facility on any the requirments about saving your participation records, they are all different.. same with "who is allowed to sign off on the charts" I've been in facilities where only a choosen few were allowed in the charts and some where the policy was less strict. Check with the Policy and Procedure Manual for your facility. Your administrator should know where a copy is for your facility.. I get alot of questions about the manual.. each facility should have one.. somewhere.. take care Quote Link to comment Share on other sites More sharing options...
Guest Guest_Margaret Report Share Posted June 20, 2006 I respectfully disagree that putting participation records in the chart causes deficiencies. Poor documentation practices cause deficiencies. There are several things to consider; if it is your organization's policy... then it has to go into the chart. Also, in a court of law your participation records may be subpoenaed whether they are in the resident's chart or in your office. When in your office you also run the risk of violating state HIPAA rules. Most surveyors consider participation records a part of the recorded documentation, as they are supportive documentation. I have had far more success defending information found in the resident's medical record then when it is found in an office. Just my experience and opinion talking here. Quote Link to comment Share on other sites More sharing options...
Guest Guest_Monarch Report Share Posted June 20, 2006 I agree with those who put the attendance sheets in the chart. I believe you have less hassle and questions if they are in the chart. I have been complimented by surveyors for having them in the charts. I believe that when you don't have them in the chart it looks like you are hiding something so surveyors dig deeper. As for the days residents are not so active is ok. They have the right to do nothing. We all feel like that on some days. Keep up the good work everyone! Quote Link to comment Share on other sites More sharing options...
JILLMARCH 0 Report Share Posted June 21, 2006 Hi I just finished my NAAP/NCCAP training and my teacher said not to put attendance records in the charts. The state doesn't need to see them. Only if they ask for them on that person.To keep them in my office for my own records. Quote Link to comment Share on other sites More sharing options...
Guest green Report Share Posted June 22, 2006 I am not sure what state everyone in this discussion is from, but I am in Texas and in the past five years I have been here, the surveyors always ask for the past three months calanders and documentation sheets. I had visited with a surveyor in the beginning of the year and she told me it would be better to have the daily sheets in the chart along with the careplan. If your careplan is being followed and you are documentation supports the residents activities, whether it their personal preference in room or group attendance, you should not recieve a deficiency. We put all documentation in their charts and the medical redord personel handle it from there. I am expecting a state survey at anytime, & have several questions for them, I plan on putting this on my list. Quote Link to comment Share on other sites More sharing options...
Guest Guest_dixie Report Share Posted June 23, 2006 I had this conversation with my consultant, I was told go ahead and put them in the chart...then when you chart everything you need is there and there for the state.....in IL they only have to be kept for 18 mo..but our medical records thins out charts regularly so only have 3 maybe 4 mo in charts........the key to the whole issue is......care plan ........if your resident does not participate because his family is there and he is content then document that.......if you have did good assessment and put in care plan then its their choice................I'd rather have my children then any other activity so why can't they? I firmly believe the whole thing is going to be resident center......it is their choice what, when, where aand how they are going to live it is our job to provide and encourage good choices for their well-being Quote Link to comment Share on other sites More sharing options...
Guest Guest Report Share Posted June 24, 2006 I have put attendance records in the charts for 2 years now and started put 1-1 records also in the charts...Mine are all done on the computer which makes it very easy to see who and what the residents are doing through out the day. We jsut had the state come in on a complaint and one of the state ladies stoped me as i was going home of course I thought Something was wrong , but she thanked me for all that i had put in the chart Esp. my 1-1 notes she said they were the best she had seen in a long time and that anything she needed was there.....As for a law suit I have had to give my attendance records and room log in the past on certain residents so it is easier for the medical records person to find then because they are in her office or the chart...... Quote Link to comment Share on other sites More sharing options...
Guest Guest_lydia Report Share Posted June 27, 2006 :-? hi all ! i live in ca. i have been though a lot of surveys and never had them ask for my daily attendance sheets only my calendars and resident council records. and i have had good reports in exits . i was not aware that you could put them in the chart. i don't think i will though if it isn't broke don't fix it. by the way my name is lydia and i'm an activities director Quote Link to comment Share on other sites More sharing options...
bigchris 1 Report Share Posted June 27, 2006 I use two different forms of participation log for my residents. In the chart, we use a form that indicates past and current participation in events that the resident likes (D) and we also have a master list for the floor that the resident is on. This makes it easier when the state surveyor walks in.... Quote Link to comment Share on other sites More sharing options...
Melete 0 Report Share Posted June 27, 2006 <~ Australia in my 8 years of expereince i have learned it is what i am directed to do by my Director of Nursing. I have always had my Activity Component of the residents care plan in with the Residents Clincal and Physical Care Plan. I have always kept my participation and attendance records seperate. More so for ease of use. Every single time a validator has come to any facility i have worked they have always asked to see the sheets. I now have a weekly overview sheet which is for a year. Much easier to use. After they leave or a new year starts, that record will go into their individual files with all the other documentation about that resident. The record sheet is about the resident. not about us per-se. when looking at an activity record they are looking for what is on that residents Activity Care Plan is what is happening on the Participation sheet. In other words. the resident is participating in what we have assessed their need to be. IF someone does not participate in group activities and that is assessed and documented then it makes NO difference if it is not marked on the attendance record. If a person has visitors every day then that is what is on their activity plan. do they participate in individual activities daily or whatever..?? if so then that is what is on their plan. I have quite a few who do not attend group activities, however if they do read, i organise the books fromt he library, they do watch the news at night, some come out for meals.etc etc ( marked as socialisation)..it is all on their plan and it is recorded on their indifivual activity record when it happens.. it may be different in the land of Oz not too sure..it sounds much the same tho.. Quote Link to comment Share on other sites More sharing options...
Melete 0 Report Share Posted June 27, 2006 oh one more thing. i have a diary and i note things dowin in it. directed by DON ( director of nursing ) etc etc to do this and do that....it covers my BUTT!! Quote Link to comment Share on other sites More sharing options...
Guest Guest_sassy_granny Report Share Posted June 28, 2006 Quote Link to comment Share on other sites More sharing options...
Guest Guest Report Share Posted June 29, 2006 Thanks everyone one for the infor - I can see that there are a variety of opinions on this subject. Our director of clinical operations wants us to start putting them in the chart so that's what we are going to do. I can see that it will make us more accountable for both our care planning and documentation, and in the long run that is a positive thing! Thanks for all your input! Terrie Quote Link to comment Share on other sites More sharing options...
paulaale 0 Report Share Posted July 28, 2006 Ok, just say I was to put my participation record in the chart like you guys are saying. You what take roll at each activity then race over to the chart to document it on the record in the chart. There is no way you are are writing care plans do assments group activites, one to ones and still touch even 1/2 the charts in your building every day. If so please tell me how. Quote Link to comment Share on other sites More sharing options...
Mandyatscr 0 Report Share Posted July 28, 2006 What we do where I work is the current months activity participation record is kept in the activities office where we mark who attended what activity on what day. Our sensory stimulation checklists are also in the office. At the end of the month we take them out of the book and then they go into the residents chart. There is usually 6 months-1 year of records in the chart and then they are thinned. Quote Link to comment Share on other sites More sharing options...
Guest Lo Report Share Posted October 19, 2006 Please, honestly, I would like to know if during Survey, have inspectors ever crosschecked/nitpicked over discrepencies concerning attendence records and what Resident is careplanned for. I have been in the field now for 8 years and not once, have they asked for attendence records. Furthermore, do all dept. disciplines even "look" at your attendence documentation as a "tool". Lastly, in our Rec. Dept. our Rec staff seems to have a handle on participatory patterns of all our residents. Jeeze, why can't progress notes alone reflect that. Finally, is it true that there are some states that do not require attendence records. What lucky States might they be. Sorry just venting!!!!!!!! Quote Link to comment Share on other sites More sharing options...
Guest Lo Report Share Posted October 19, 2006 I would really appreciate hearing from someone who has been cited on their attendence records. What was the outcome? What was the plan of correction? How did it impact? What were the consequences to the facility? Quote Link to comment Share on other sites More sharing options...
Guest Guest_Miguel Report Share Posted October 19, 2006 I created a three month participation record that is very simple and covers everything, (No highlighting) additionally, we have the resdients Room Visit schedule on the back (3 months at a time) so that is recorded... and... Attached to every residents Participation Record & Room visit log we have that residents Care plan (a copy of the one that is placed in their chart) If anyone would be interested in any of these they are in Microsoft Word format and are very easy to use and change for every quarter. ALSO... I do my monthly calendar in Microsoft word and would be willing to share it with anyone if you want.. all I need is for you to e mail me at msarasa@thevillagehemet.com -Miguel Quote Link to comment Share on other sites More sharing options...
Guest Guest_Miguel Report Share Posted October 19, 2006 I created a three month participation record that is very simple and covers everything, (No highlighting) additionally, we have the resdients Room Visit schedule on the back (3 months at a time) so that is recorded... and... Attached to every residents Participation Record & Room visit log we have that residents Care plan (a copy of the one that is placed in their chart) If anyone would be interested in any of these they are in Microsoft Word format and are very easy to use and change for every quarter. ALSO... I do my monthly calendar in Microsoft word and would be willing to share it with anyone if you want.. all I need is for you to e mail me at msarasa@thevillagehemet.com -Miguel Quote Link to comment Share on other sites More sharing options...
Guest Guest_asandlin Report Share Posted October 19, 2006 Please don't forget me. I have been an AD for 3 years and have not found any partivipation form I like yet. I've tried making my own, ordered from Briggs, and took hints from other centers. Please e-mail me all area of activity forms. Thanks asandlin AD, Huntsville, AL hvlactivity@ahcthm.com Quote Link to comment Share on other sites More sharing options...
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