Documenting for Volunteers
The quality and quantity of documentation is also important. The following is a list of issues to keep in mind when writing your documentation (check with your own volunteer managers for more specific details and policies):
• Just the facts, please! Document exactly what you see and hear. Documentation should record what happened and the patient/family's
response. It is not appropriate to report your interpretations or diagnoses. Instead document behavior, what the patient/family did or said (use quotations).
• Be specific and to the point
• Avoid unnecessary or unrelated information, or subjective opinions
• Document objectively and avoid assigning blame
• List your goals with the patient and family (“companionship” “respite” or other goals)
• List your interventions (actions) with the patient and family (“conducted a lifetime reflections life review”)
• Document ALL interventions including phone calls, attempted visits and bereavement visits and calls
• Document discussions with other team mem¬bers (“Called nurse Pam Smith to report that patient was in pain”)
• Make sure abbreviations are standard for your program or better yet, don’t use abbreviations.
• Timelines are of vital importance for optimal patient care, so note times of important observations
Just remember the rule, "If it isn't documented, it didn't happen. "
Always remember to document if you see decline in a patient from prior visits. (Example: “Patient became short of breath after only a few sentences, whereas on my last visit she could talk longer” or “Patient spent more time sleeping on this visit than on my last visit”) In order to remain eligible for hospice services, patients must be “declining” according to specific Medicare regulations. Your notes could help to make (or break) the case for keeping a patient on service. Be observant and don’t forget to report what you see.