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:
A few words about Interdisciplinary communication....
Interdisciplinary Communication
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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...
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