Documentation Tips

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Documentation in home care is essential to ensure reimbursement and to provide evidence of patient outcomes and the quality of care and improvement.

It’s important that it substantiates the Skilled Need, the Homebound Status and the measurable Goals and Outcomes and is consistent with the data found in the patient’s OASIS documents. 


Here are some resources to help ensure your documentation is the best it can be:

  • Homebound Statements
  • Other Documentation tips from Home Health101.com
  • One of the most important books you can have in your nursing library is The Handbook of Home Health Standards by Tina M. Marrelli RN, MSN, MA, FAAN. There is now a 2018 edition which includes OASIS, information about the new COPs which includes changes in QAPI measures and care planning. It is a MUST HAVE for all home health care staff, sales and marketing and management.


A few words about Interdisciplinary communication....

Interdisciplinary Communication

One thing home health care will NEVER be is without the mounds of
paperwork. Even if that paperwork is "paperless" through the use of
laptops or PDAs, documentation remains cumbersome.


Agencies strive to streamline the process, and pride themselves on 

developing a checklist for every possible scenario. The bottom line is, 

documentation is key to reimbursement. It provides proof of the care 

given as well as the response to that care. It tells the story of where 

you are in the care plan for the patient. What has been accomplished, 

and what is left to be done.

Communication between disciplines is essential, and often the target 

of surveyors. It is most often under-documented or missing entirely. Home Health is a TEAM effort and needs to be represented as such. 

When you discuss progress, plans, etc. with another discipline, 

take credit for it. Often this is the best insight into the medical 

necessity (skilled need) of the care. It also demonstrates goals and outcomes. 

 Even just a few words can make a big difference...

  • Provided report on patient's elevated B/P status to PT
  • Informed PT of impending nursing discharge next week if wound healed
  • Discussed changes in ADL limitations with CHHA and revised POC
  • Instructed CHHA to have patient wash upper body and have pt wash lower body
  • Requested OT to instruct cg in bathing/grooming techniques
  • Instructed LPN (LVN) to have cg return demo BG testing today
  • Informed RN of PT goal to have patient independent in 

    bed-to-chair transfers this week


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For more documentation help, sign up for my Online Course: Documentation Basics for Skilled Home Health Care 

The price has been reduced to 

  • $99 for individuals 
  • $499 for (multiple license use) agencies to use





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