Home Care DocumentationoIn 2000, Outcome and Assessment Information Set (OASIS) was mandated by the federal government. OASIS tool accurately measures the patient’s status during home care. This allows for a basis of measurement for patient outcome. Long-Term Care DocumentationoThe Resident Assessment Instrument (RAI) governs documentation in long-term care settings.The goal of RAI is to optimize the resident’s quality of care and quality of life. The RAI is a very comprehensive assessment tool. Written Handoff SummaryoA handoff, or transfer or care for a patient from one health care provider to another, significantly increases the risk of errors. Handoffs do not only occur during a shift change, but also when a patient is transferred from one area of the hospital to another. oTo minimize potential errors from lack of information, it is important to provide specific assessment on a written transfer in addition to a verbal report.ReportingoReporting occurs at handoffs, during patient rounds, during patient andfamily care conferences, and when calling or texting a provider to report a change in status or provide requested information. oSituation, Background, Assessment, and Recommendations (SBAR) ModelSBAR improves communication between health care professionals. Situation: State concisely why you are communicating.Background: Describe the circumstances leading up the current situation.Assessment: Give objective and subjective data pertinent to the situation.Recommendation: Make suggestions for what needs to be done to manage the difficulty.