documenting visits in patients records

[susan pauly]

We are required to document volunteers assigned to each patient in our case conference notes in the medical record.

 When we have several volunteers working 3/4 weekly shifts at a hospice unit where there are 5 patients at a time.... Do we need to document in each patients record every volunteer that was on duty at the time of thier stay?

[susan pauly]

Thanks Greg,
This is excellent advise- " Incidental interaction" is a perfect way to describe it and exactly the issue that concerned me. All volunteers who go to the unit have completed all necessary training to perform both tasks.
Thanks again, I think this clears things up for us and re-affirms we will be doing the right thing!

[Greg Schneider]

It sounds like your volunteer's activities fall into two categories: Direct Patient Care and Non-Patient Care. You should document them separately. Volunteers that go to the hospice unit to provide whatever support is needed fall into the latter category and their activities should be documented as such. A volunteer's incidental interaction with patients while doing such work would still fall into the latter category. Volunteers that are specifically assigned to visit with certain patients, should be documented as Direct Patient Care.

This subtle point also has many implications as far as volunteer training and volunteer support is concerned so it is a good idea to make a clear distinction among your volunteers as to which category they fall into.

If volunteers are intended to serve both functions then they should be classified in the predominant category. The reporting requirements for supporting the hospice team are different for each category. Those volunteers serving in the Direct Patient Care role typically create intimate relationships with the patient and their family. Therefore they are privy to communications with the patient and family and can develop insights that are very useful to the rest of the team. This is the primary reason the two categories should be considered as being distinct as they serve different roles in the hospice organization.

Greg Schneider
HCF Creator
President, HVA

[Jennifer Thompson]

I agree with Greg, you need to have the volunteer document on each patient they are assigned. Sounds like a great way to use volunteers, can you give us some more information on what the volunteers are exactly doing, (one-on-one visits, administrative, etc)

Jennifer Thompson, CVA
Rivercross Hospice - Tulsa, OK

[susan pauly]

Thanks for your feedback. The volunteers sit with patients who are alone and talk, or stock the family area, they bring water and coffee to pts and family members, they also do some clerical work if needed, for example filing or answering phones. They may or may not have direct contact with every patient, and there is not usually a request or assignment in place for them, so that is why there is some confusion on how to document. I am not sure it is necessary for there to be a note in every single pts record? I want to do what is necessary, but not any uneccesary work.

[Greg Schneider]

I would say that you should be documenting each patient's record with the volunteer that was specifically visiting them. I would assume that the patient's plan of care stipulates that they will receive a visit from a volunteer for a certain number of hours each week. The recordkeeping goal should be to reflect that the patient is receiving care according to plan. If a volunteer visits multiple patients simultaneously the records should reflect a proportionate amount of time for each patient present.