10 Tips for Better Home Health Documentation
While documentation in the home health setting may feel cumbersome, it’s a critical facet to care because documentation tells the story of each patient’s journey throughout the entirety of each episode of care. From initial admission through the treatment process and discharge, important details are carefully noted, allowing you and other caregivers to spot patterns and potential challenges so you can provide the absolute best level of care possible and avoid potential setbacks.
Looking for a free resource to help with OASIS documentation in home health? Here is our free OASIS-E cheat sheet.]
Given the pressures of limited time and new regulations, it’s understandable that many healthcare providers find accurate and efficient documentation difficult. However, it might help to view documentation through a different lens. With that in mind, the tips below will help you document more effectively and efficiently to communicate crucial information to those who need it.
Document Objectively
Remember that any reviewer of a patient record does not have the depth of knowledge that is gained from providing care. Because of this, document objective and clear findings and information, including the patient’s problems and needs, the care provided, and how the care is directed toward goal achievement and discharge.
The contents of the documentation should convey to any reader, such as your manager, a state or accreditation surveyor, or a payer, the status of the patient, adherence to the ordered plan of care, and progress toward individualized patient-centered goals.
Document both medical necessity and homebound and support other coverage criteria in your documentation. For home health documentation and hospice care, use objective descriptive terms that help the reviewer “see” your patient and their functional and other limitations that support a knowledge of the tenets of coverage for your program.
Take an overall look at the documentation and try to understand if it’s looking at things objectively. Does it tell the story of the patient, their care trajectory, and the interventions provided and implemented based on physician orders? If so, you’re on the right track.
Document for the Entire Care Team
Make sure calls and other communication across team members and the physician are documented. If the patient experiences a change in condition, does the documentation explain what the findings were or what occurred with the patient that necessitated the call? Does it include what actions were ordered or changed and implemented as well as the patient’s response to these interventions and care?
It’s important to ask whether the patient’s areas of risk for hospitalization are noted and observed? Are the interventions to prevent this reoccurrence documented?
Additionally, each visit by a clinician should be documented, including the elements of assessment, care planning, interventions and actions, and continued evaluation
Reflect Family & Caregiver Needs in Documentation
Documentation should include patient and family caregiver education, their responses to and demonstration of the education provided, as well as results of the education (for example, medication administration). The care entries and overall information needs to reflect the level of care expected by healthcare consumers, caregivers, and their families.
Demonstrate Compliance and Quality
Overall, the clinical documentation should demonstrate compliance with regulatory, licensure, and quality standards. Ask yourself the value question: Would I pay for this care or visit? Is this reflected in the clear documentation that supports medical necessity and coverage?
Need additional assistance developing or advancing your documentation skills? Be sure to check out the following Medbridge courses:
- Identifying, Communicating, & Documenting Patient Change in Condition
- Orientation: An Overview of Documentation Requirements in Home Care
- Medicare Coverage and Documentation Requirements: The Fundamentals
Adapted from the “Handbook of Home Health Standards: Quality, Documentation and Reimbursement.” (Marrelli, 6th ed). Reprinted with permission. www.marrelli.com
