Clinical Nursing Documentation is Critical to a Patient’s Record

Are you aware that home health regulations Conditions of Participation (CoPs) indicate the clinical record for patient’s must contain progress and clinical notes?  The Medicare Claims Processing Manual, Chapter 10, has specific instructions that HHAs are required to report all services provided to the beneficiary during each episode, which includes reporting each visit in line-item detail.  As such, it is expected that the home health records for every visit will reflect the need for the skilled medical care provided.

Clinical notes are also expected to provide important communication among all members of the home care team regarding development, course and outcomes of the skilled observations, assessments, treatment and training performed.  Taken as a whole, the clinical notes should tell the patient’s story toward his goals as outlined in the Plan of Care.  This documentation serves to demonstrated to outside adjusters the reason skilled services are needed.

Clinician documentation notes must contain the following, as appropriate:

  1. The history and physical exam pertinent to the day’s visit, including the response or changes in behavior to previously administered skilled services, AND
  2. The skilled services applied on the current visit, AND
  3. The patient/caregiver’s immediate response to the skilled services provided; AND
  4. The plan for the next visit based on the rational of prior (and that day’s) results.

Clinical notes should be written to adequately describe the action of the patient to his skilled care, provide a clear picture of the treatment, as well as the “next steps” to be taken.  It’s inappropriate to use vague or subjective descriptions for he patient’s care.  An example of inadequate documentation would include:

  • Patient tolerated treatment well
  • Caregiver instructed in med management
  • Continue with POC

As a clinician, your documentation should include objective measurements of physical outcomes of treatment in a clear, precise description.  Include the changed behavior due to eduction program so that all agency staff members can pick up the chart and follow the results of applied services.

If a skilled service is being provided to maintain the patient’s condition or prevent or slow further deterioration, the clinical notes must include:

  1. A detailed rationale that explains the need for skilled service in light of the patient’s overall medical condition and experiences,
  2. The complexity of the service to be performed, AND
  3. Any other pertinent characteristics of the beneficiary or home.

Once you’ve written your skilled care review, read over it to ensure it’s accurate, complete, and objective. Payment for your agency could be impacted by clinical documentation so strive every day to ensure all appropriate information is present for each patient.

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