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Document Type:
HCA Policy
Effective:
February 2, 2026
Overview
The client’s health record is evidence of care provided to the client and is the primary communication tool between team members. Documentation contributes to safe client care and safe practice environments. HCAs are accountable for ensuring their documentation accurately communicates the care they provided. It is a professional expectation and regulatory requirement for HCAs to follow the documentation principles to provide quality documentation.