Comprehensive home health documentation is necessary to ensure both quality patient care and proper reimbursement. Stronger focus on investigating what CMS deems as fraudulent activity combined with efforts to ensure more accurate reimbursement means that home health agencies must take steps to ensure documentation integrity. Tina Marrelli, MSN, MA, RN, FAAN, President of Marrelli and Associates and author of The Handbook of Home Health Standards offers some great information about the importance of home health documentation and problems to avoid.

Why is home health documentation so important?

Complete, accurate clinical documentation is vital for a number of reasons. It is used to communicate a patient’s “medical story” to staff and provides evidence of positive outcomes, quality care, and improvement. It is also the basis for which you are paid.

What is the goal of home health documentation?

When documentation and processes/systems work, everyone benefits. All information is aligned, legible, complete, and congruent. Care is coordinated and communicated across disciplines in a timely manner, enabling staff to have the information they need to review notes, make care decisions, bill, and more.

How does good clinical documentation protect your agency?

You are what you document! Your documentation shows the quality of care you give your patients. It protects you from malpractice and minimizes your risk of takebacks and/or audits. Additionally, well organized documentation makes it easier for surveyors to review your care practices and find the information they are looking for quickly and easily. How does Medicare know if you are doing what you are being paid for? Through your documentation!

What should be included in my home health documentation?

Your documentation should include:

  • Individualized care plan
  • Assessments and the patient’s clinical status
  • Problems
  • Goals
  • Interventions and the patient’s response
  • Variances from expected outcomes (medications, procedures, protocols) and the action taken
  • Communication with physicians and others
  • All unusual patient occurrences or incidents

Missing, Incomplete, or Incorrect Documentation

Documentation that doesn’t clearly and accurately convey a patient’s care plan can lead to a myriad of issues for a home health agency, including reduced reimbursement, increased risk of audits or takebacks, patient safety issues, inadequate care coordination, and the appearance of poor quality to the public and referral sources.

Many times, missing, incomplete, or incorrect information occurs when clinicians are in a hurry to complete their documentation. To alleviate this issue, many EHRs have documentation templates, checkboxes, and cloning abilities that offer a fast way to duplicate data. However, this often enables clinicians to cut corners, which can lead to inaccurate documentation. According to the American Health Information Management Association, “Automated insertion of previous or outdated information through EHR tools, when not modified to be patient-specific and pertinent to the visit, may raise significant quality of care and compliance concerns—creating a potential for medical liability issues.”

Recognizing that every patient’s medical story is unique, and ensuring that documentation is specific to him or her is vital to warranting that every patient receives the quality of care s/he needs. To address this, HEALTHCAREfirst offers firstHOMECARE EHR software with CAREpliance Technology, a thoughtfully designed clinical workflow that follows standard patient care processes and equips clinicians with the most thorough, evidence-based guidance available to reinforce sound decisions at the point of care. When problems are identified in the assessment, the system suggests goals and interventions, allowing the clinician to easily customize the care plan and build a story for the patient, something surveyors are looking for in site audits. The result is comprehensive care with the very best possible outcomes, and consistent clinical documentation that ensures compliance and protects home health agencies.

To learn more about how HEALTHCAREfirst can help you agency meet regulatory requirements and improve your clinical documentation, schedule a demo today!