Documentation

Who does the nurse assessment, and what must the nurse sign?

A nurse licensed in Georgia must do nursing work. Georgia’s rule says personal care assistants may not provide nursing services unless they qualify as nursing personnel. Clinical or progress notes for nursing clients must be signed and dated. The nurse signs the clinical parts herself.

The nurse’s role is to judge needs, not just to fill forms.

What Georgia’s private home care rule says:

  1. Nursing personnel must be licensed in Georgia.
  2. Personal care assistants may not do nursing services unless they are qualified as nursing personnel.
  3. Clinical or progress notes for nursing clients must be signed and dated.
  4. The file must show supervisory visit findings.

The CCSP and SOURCE manual also says a Registered Nurse must live in Georgia, not just hold a license there.

What to keep:

  1. The assessment, dated and signed.
  2. The service plan that came from it.
  3. Notes on changes in condition.
  4. Follow-up on incidents.

Software can draft notes, but a nurse must read and sign anything clinical. The signature means she checked it.

If your agency does not employ a nurse, ask your program manager who is allowed to do assessments for your service.

How CareBravo® helps

Cary® drafts and a person confirms; the nurse signs every clinical field.

Sources

Reviewed by Beth Bledsoe, Care Business Advisor®, 28 Oct 2026. Rules change. Confirm with your state Medicaid agency before you act.

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