On 10/14/16 I met with Zarqa to discuss the visit that was completed on 10/13/16. At that time there was no documentation in Carma for the client and I wanted to get a brief synopsis of her visit. Zarqa stated that the client had visited her primary care physician the day before and was diagnosed with osteoporosis and high cholesterol per her lab results. In addition, Zarqa stated that the client was taking medications for her conditions.
Shortly after our initial conversation, I spoke again with Zarqa to get additional information about the medications the client was taking and Zarqa stated that the client was not taking any medications and that she did not have the diagnosis she had the test completed.
Once Zarqa completed her documentation, the documentation stated that the client had a diagnosis of osteoporosis and high cholesterol. A telephone call was made to the client to follow-up on the visit. The client stated…show more content… Zarqa was also asked to correct the documentation.
On 10/26/16 I spoke with Zarqa about documenting her visits in Carma. I explained what her documentation should contain. I also informed Zarqa about the items that need to be corrected in her current documentation in Carma. Changes were made in Carma but the changes do not reflect the items that were discussed.
In addition, we discussed
0n 11/02/13 I received a text message from Zarqa stating she needed to have a client added in Care at Hand. I instructed Zarqa to contact Erica to assist her with adding the client in Care at Hand. Zarqa contacted Erica and informed Erica that she was unable to complete the Care at Hand during her visit because the client was not added. Each coach was notified on 10/18/16 that they have the ability to add clients in Care at
