title: Just the facts, please: a guide to effective documentation.
abstract: Although most health care professionals would wish it otherwise, documentation will never be eliminated completely. It can be ignored and complained about, but documentation will always be there to remind us, "If it wasn't documented, it wasn't done." Home care providers need to be cognizant of the imperative for effective documentation. Corporate compliance initiatives, fraud and abuse issues, and changes in reimbursement mechanisms make documentation more important than ever. Home care providers must create an environment conducive to effective documentation practices.
authors.affiliation: Visiting Home-maker Service of Hudson County, Inc., Jersey City, NJ, USA.
authors.forename: C L
authors.initials: CL
authors.lastname: Mahler
mesh_terms: D004282:Documentation / Q000191:economics / Q000592:standards*; D004608:Eligibility Determination; D017408:Guidelines as Topic; D017048:Health Care Costs / Q000706:statistics & numerical data; D006699:Home Care Services / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D008499:Medical Records / Q000191:economics / Q000331:legislation & jurisprudence / Q000592:standards*; D009737:Nursing Records / Q000191:economics / Q000331:legislation & jurisprudence / Q000592:standards*; D011787:Quality of Health Care / Q000331:legislation & jurisprudence / Q000592:standards; D012051:Reimbursement Mechanisms / Q000191:economics; D012308:Risk Management; D014481:United States