Orientation: An Overview of Documentation Requirements in Home Care

Presented by Tina Marrelli and Kim Corral

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Video Runtime: 59 Minutes; Learning Assessment Time: 31 Minutes

Today's home care clinicians must have an understanding of the trends, regulations, and other external factors that impact care provided and the documentation surrounding care. Home care is a global term, and home care services can range from solely personal care services (non-medical) to very skilled levels of care with licensed nurses providing care to medically fragile adults and children. Because of this, there are many models and methods of delivering home care. For purposes of this course, we will be focusing primarily on the provision of “visits” as the primary model of home care vs. hourly care. Medicare is the largest payer of home health services, and visits are the usual unit of care delivery. Medicare sets the standards for home care, regardless of the payer. It is for this reason that an overview of documentation requirements is the first course. The differences in documentation requirements for home care versus other settings (e.g., OASIS) will de discussed, and the purposes of documentation, supporting medical necessity, and coverage criteria will also be addressed. This course is designed to provide tangible tools for both clinicians and leadership/management to apply as they improve their processes and practices related to effective documentation in home care.

Meet your instructors

Tina Marrelli

Tina Marrelli is the president of Marrelli and Associates, Inc., a publishing and consulting firm working in home care for more than 30 years. Tina is the author of 13 books, including the Handbook of Home Health Standards: Quality, Documentation, and Reimbursement (6th edition, 2018). Other books include A Guide…

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Kim Corral

Kim is a registered nurse with a master's degree in education and more than 30 years of home health experience. She is an experienced leader in home health care, having held both clinical and operational positions at regional and national levels for large corporate home health organizations. She brings a passion for providing…

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Chapters & learning objectives

1. Welcome to Home Care and Home Care Documentation Requirements

This chapter sets the stage for why home care and its documentation and related requirements are different from those of other settings. The external framework is Medicare and the Medicare Conditions of Participation (CoPs) related to documentation standards, compliance with state regulations, agency policy, accreditation, and other relevant regulatory and practice manuals. Other external drivers that impact care and documentation are also addressed.

2. The Purpose and Multifaceted Roles of Home Care Documentation

This chapter will address the purpose and roles of documentation. The documentation should "tell the patient's story," support communication and care coordination, and facilitate the care planning process. Care coordination will also be defined from a practical perspective related to care, the individualization of care, and the documentation implications.

3. Why All the Scrutiny and Oversight of Home Care Documentation?

This chapter will explain oversight as it relates to home care and home care documentation. Who is accessing your documentation, and why? There are multiple organizations reviewing your records, some of which will be discussed in this chapter. Home care integrity, knowledge of and adherence to the rules, and the interface of regulation, payment, and quality in home care and home care documentation will also be discussed.

4. A Patient Example with an Assessment

This chapter begins with a patient example to highlight the detailed documentation needed to support coverage and other tenets of home care. Through this example, we will demonstrate the documentation standards required for a comprehensive assessment and why this is important. We will also delve into the definition of "homebound" and other criteria that must be met for appropriate admission. We will explore the required elements of a comprehensive assessment, including how to assess for the medical, nursing, social rehabilitative, and discharge planning of the patient, and the need for physician orders will be addressed from a practical and regulatory perspective.

5. Value of Documentation of the Plan of Care from a Number of Safety, Quality, and Payment Perspectives

In this chapter, our patient example continues as we review supporting medical necessity in communication and care coordination for our sample patient. The care planning process continues, looking at using our critical thinking skills of reasoning, analyzing, evaluating, problem-solving, and decision-making to create the best individualized plan of care. The planning process continues with the collection of information, reflection, formulating the plan, and implementing the plan. In this chapter, it is emphasized that the patient's holistic assessment drives the care. In this example, you'll see that problems derived from the assessment deserve thoughtful consideration and care planning with a clear explanation as to why the patient does or does not need care for this the identified problem or deficit.

6. Fundamentals Remain: The Numerous Roles Documentation Plays in Effective Patient Care and Care Planning

This chapter reviews the foundational tenets of effective documentation, with an emphasis on best practices and standards, to meet numerous regulatory requirements that are evidenced in documentation.

More courses in this series

Welcome to Home Care: An Overview

Kim Corral and Tina Marrelli