SAMPLE POLICY WORK

Service Documentation

Service documentation captures the details of care delivery and is critical for internal quality assurance and regulatory compliance.

Documentation Requirements

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Daily Service Logs: Every service encounter must be recorded in the daily service logs. These logs include the date, time, nature of the service provided, observations from the staff’s direct interaction with the client, and any relevant deviations from the prescribed care plan. Progress Notes: Detailed progress notes are required at the end of every shift or service session. These notes should reflect client condition changes, achievements, or issues that require follow ‑ up. Incident Reports: Every incident — ranging from minor accidents to severe medication errors — must be documented immediately using the standardized Incident Report Form. Communication Records: All internal communication regarding client care decisions is documented, including emails, memos, and minutes from multidisciplinary meetings. Quality Assurance Documentation: Documentation from routine audits, supervision sessions, and review meetings is integrated into the client file for future reference and continuous improvement.

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Procedural Guidelines for Service Documentation

Real-Time Documentation:

– Staff must complete logs and notes in real time or no later than 24 hours after each service interaction. 2. Standardized Templates: – All documentation is recorded using standardized electronic forms that ensure consistency and completeness across all departments. 3. Timely Updates: – Any adjustments to the client’s service plan must be documented immediately and trigger an update notice to the supervisor. 4. Audit and Verification: – The Quality Assurance Team conducts monthly audits of service documentation to verify the accuracy and completeness of records. 5. Confidentiality Protocols: