Documentation Tips

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

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

Homebound Statements

Other Documentation tips from Home Health101.com

Documentation Guidelines 

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.

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

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

necessity of the care.

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 ADL limitations with CHHA

** Instructed CHHA to have patient wash upper 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.





 

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