Staff Education – Documentation and Compliance

Staff Education Documentation & Compliance

This is a REQUIRED training. Please read and complete the accompanying quiz.

All documentation must be completed within one day of the date of service. It is important to document information timely to capture all the client’s pertinent information or changes.

Any communication to the physician needs to be documented timely and entered into the chart within one day of the communication.

Compliance with physician orders is required and any deviation from the physician order must be communicated to the clinical supervisor immediately. Any changes in physician orders not only require notification to the physician but a signed interim order from the physician.

  • Includes treatments not carried out as ordered

  • Includes medications not given as ordered

  • Includes any supplies not delivered or lack of medical supplies in the home for any reason

o Example: if a patient needs a G-tube change and the medical supply company has not delivered the G-tube timely, the physician must be notified, and an interim order sent.

Please note if there is a compliance issue and it is due to insurance or supplies, please notify the Clinical Supervisor before the end of the shift/visit about the issue and document the communication.