MyHomeCareBiz would like to take you back to the basics of home health documentation because the professional responsibility related to this is an essential component of home healthcare.
Proper documentation allows continuity of care, a way to let other health care workers know what we have done and is a legal documentation on the patient. The major purposes of documentation are the following:
- Creating a record of the patient’s ongoing assessment and care
- Creating a working document that is the plan of care
- Coordination of services provided
- Evaluation of the effectiveness of the care provided
- Facilitation of communication with staff, caregivers, or other providers
- Reimbursement for services provided
In health care, always remember, “If you didn’t document, you didn’t do it!” The quality of the care provided to patients can only be measured by the quality of the documentation and the final rule for the Conditions of Participation (CoPs) for Home Health Agencies (HHAs) requires the documentation to be ‘living and breathing’ which makes it really challenging and fun.
To ace the state audit, your documentation should have the following basic components:
- Patient Information - consists of all information known about the patient when the patient is first admitted to the health care agency. It includes the nursing assessment, the physician’s history, social & family data, and emergency contact information among others. Some of the basic information can be entered into the chart during the intake process by the agency administrative staff, but needs to be validated by the assessing clinician during the first visit to ensure accuracy.
- Problem List – these are the deficits that are reflected on the OASIS based on the assessment conducted by the clinician. These should serve as the basis for developing the plan of care. The problem list is continually updated as new problems are identified & others resolved on each and every visit.
- Plan of Care – care plans are developed by the person who lists down the problems. This serves as the blueprint which focuses on increasing patient participation and interdisciplinary collaboration with the central goal of ensuring better outcomes. And just like the problem list, this is regularly and religiously updated as new problems arise and existing problems are resolved.
- Progress Notes – chart entry made by all health professionals involved in patient care. This should reflect how the plan of care has been executed.
Delve into the basics and you'll be sure to improve your documentation skills. For more tips on safety guidelines when documenting electronically, grab the bonus download included in this blog.