Patient Records

We develop, receive and use various documents to help us understand your needs, abilities, strengths and preferences. These records are maintained as part of our general case management activities and are intended to:

  • record services and care provided to you
  • monitor your response(s) to the services provided
  • identify if, when and what changes might be needed to your Care Plan
  • record the number of service hours provided to you for billing and payroll purposes.

This means, as our client, we will have information about you on file. The usual types of documents we use are listed below. Depending on the specifics of your case, we may only use some of them and/or we may require additional ones that are not listed:

  • Identifying data; (e.g., name, gender, birth date, address, telephone number, next-of-kin, emergency contact number)
  • Initial request for service or your initial referral from another source
  • Assessment details
  • Care Plan
  • Consent for Referral & Release Information
  • Service Agreement
  • Progress Notes
  • Direct Care Worker Notations
  • Service Schedule (hours, dates & Direct Care Worker assigned)
  • Billing documentation
  • records of Supervisor’s visits
  • Client Rights information
  • Physician's orders
  • Documentation on Health Care Directives (if applicable)
  • Complaints
  • Compliments
  • Incident Reports
  • Client Satisfaction Questionnaires

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