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 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
Here's a great source of Documentation Guidelines (it's a .pdf file so you need Adobe Reader) from the College of Registered Nurses in Nova Scotia.
