Documentation and Record Keeping

Don’t chart for someone else or let anyone else chart for you. Do not let anyone use your clock-in system, when things get busy we tend to take shortcuts, but with our record keeping it must not be done. It’s illegal and unethical.
  • Your electronic task sheets indicate what services you provided for your client during your visit, take the needed time when filling it out.
  • Each task sheet is reviewed by the RN for accuracy.
  • Do not clock in or out early. If this should happen , remember you must inform the office as we are responsible to Medicaid . They want to know why that occurred.
  • Medicaid is very specific with their authorizations and it is up to us to follow them.
  • We have clients that use a paper task sheet (DDSN, VA)
  • It is the responsibility of the aide to make sure you have clean copies of these.
  • DO NOT scratch out on these sheets, do not use White Out or write over. Everything needs to be legible. They must be accurately dated, signed by the aide and the caregiver or family member and turned in weekly. A new sheet must be used each week.
  • If you encounter any difficulty using the Care Call system or the APP, please reach out to your office team.
  • Documentation is not difficult, but it must be done properly. Your charting is just as important as that of every other member of the health care team. Your observations provide a baseline of each clients status and can be the key to noticing a change in the clients condition.
  • Remember that your clients are counting on you, so take pride in your charting.
  • When you forget to clock in/out a blank task sheet is still printed. This sheet is reviewed by Medicaid and it now looks like you did not assist the client at all.
  • So that being said, while clocking in/out drives the way the office does your payroll, it is also very important if not more important to Medicaid.
  • Take the time and fill it out accurately indicating the tasks that you assisted your client with that day. Remember we are a NON-MEDICAL provider and while you may see some medical tasks on that sheet, DO NOT check them. These sheets are used by various Medicaid providers.
  • Remember if it is not charted, you didn’t do it.

Documentation and Record Keeping Quiz

    * Required Information

    1. It is ok to have someone clock in and out for you.*


    2. On paper task sheets it is ok to use white out as long as i write clearly over it.*


    3. Documentation is not difficult but it must be done accurately *


    4. Medicaid is very specific with their authorizations and we must follow them.*