Manual: Home Infusion Therapy Policy and Procedure Manual (Ver 4) Department: INFUSION THERAPY SERVICES External Reference: (JC PC.5.10, IM.6.20, CHAP TII.6a, TII.6b)
As the health care industry’s most comprehensive library of customizable policy and procedure templates, MCN Healthcare’s Home Infusion Therapy Policy and Procedure Manual includes this customizable template, Progress Notes. MCN’s policy library helps you meet compliance with Joint Commission and federal regulations including CMS, CDC, OSHA, OIG, HIPAA and more. MCN provides more than 80 health care specific policy and procedure manuals for Acute Care Hospitals, Ambulatory Care, Behavioral Health, Home Health, Physician Practice, and Long Term Care. MCN’s policy and procedure manuals focus on the latest healthcare "hot topic" issues related to patient safety and prevention of medical healthcare errors. Here is some sample content from Progress Notes:
| | POLICY:
The client home care medical record will include documentation of communications regarding conclusions and findings of client medication monitoring, documentation of actions and interventions, client response to treatment and outcomes associated with drug therapy.
PROCEDURE:
The pharmacy chart will include clinical progress notes for each client. Communication or activities to be documented in the progress notes include:
Initial assessment information
Client's current condition
Outcomes and responses to medication and treatment
Rationale for revising the Pharmacy plan of care,... |
| Second excerpt: |
| | ...progress notes. The forms may include preprinted case conference notes, or the Summary of Client Status Form.
The following information will be included in each progress note:
Client's name
Date of progress note
Name of persons interaction occurred with
Method of communication
Actual events to be documented
Signature of staff member charting
Documentation will be clear and concise. Handwritten notes will be legible.
Progress notes will be written and filed in the client record... |
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