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Tips for Effective Documentation of a Home Visit

 

 
 

Do

Don’t

 

   Always refer to WV Birth to Three policy and procedures, including Documentation and Service Definitions for specific documentation requirements

   Do not rely on what another practitioner has told you about your responsibilities for documentation

 

   When documenting a direct service in the service activity notes, remember to:

   Name the outcomes that were addressed during the visit

   Record intervention supports you provided such as:

   Did you provide the family with information related to a concern or outcome?

   Did you demonstrate a new strategy for promoting development in the area of the outcome?

   What was the result of what was discussed or tried during this visit or since the last visit?

   What will the family/professional do before the next visit?

   Don’t write ”all” – if was all, list each outcome

   Don’t record only observations of what the child did or the parents said. You should record the parent’s questions or concerns and the child’s response to strategies and progress toward outcomes. Remember this note also documents the service for which you billed. The note must include what you did – discussed child progress, answered questions, gave additional strategies.

   Don’t forget to include specific start and stop times before you ask the family to sign the note.

   Never ask the family to sign a blank note or form

   Don’t forget to have the family sign and date the note at the end of each visit.

   Don’t write the note in technical terms the family will not understand.

 

   Encourage families to keep their copies of Activity Notes and other BTT documentation to share with family members, physicians or other BTT team members.