Can a facility obtain information omitted from the Health assessment form verbally from the physician?

Obtaining omitted information from the health assessment form verbally from the physician is acceptable, provided that this information is documented in the resident's records. This ensures that there is a formal and traceable record of the health assessment, which is crucial for maintaining continuity of care and for compliance with healthcare regulations. Documentation helps to ensure that all relevant information is readily available to any healthcare provider involved in the resident's care.

Additionally, having clear, written documentation promotes accountability and reduces the risk of miscommunication among care providers. While verbal communication may be efficient in certain scenarios, particularly when immediate information is needed for decision-making, it is critical that such information is captured in the resident's records in order to maintain an accurate and comprehensive medical history. This approach balances the need for timely information with the necessity of maintaining thorough documentation.