Best Practices for Documenting Skilled Home Care Services

The Medicare and insurance documentation regulations for skilled home care services change so rapidly that it can be a challenge to keep up and stay compliant. Add in the fact that a significant amount of detailed information is required, and you may find that your agency is challenged with keeping it all straight. When your team is documenting the skilled services they provided, it’s important for them to be thorough, yet succinct.

To help your team ensure nothing is missed, we’re going to break this down into four manageable categories and highlight the documentation requirements for each:

1. Documenting in the Patient’s Home Care Medical Record
All care should be documented in the patient’s home-care medical record and should include the following:

• Initial assessment
• The initial plan of care
• Updated plan of care
• Intermittent physician orders
• Interdisciplinary notes

For each skilled nursing and/or ancillary service visit, a progress note should be present in the patient’s medical record within 24 business hours of the visit. The progress note should support the plan of care and include accurate and specific descriptions of the visit.

2. Skilled Progress Note
With the above in mind, the skilled progress note should include at minimum all of the following:

• Current medical condition and mental status
• Homebound status
• Physician-ordered care given to the member during the visit
• Follow-up on previously identified problems
• New onset of symptoms
• Teaching and training activities done with the member, caregiver, and/or significant other, which can include education regarding disease process, as applicable (documented from start of care date).
• Response, capability, and accuracy of the member, caregiver, and/or significant other to perform the required care as taught.
• Outcome of interventions
• Date and time that services were provided, including signature/title of the person providing those services.
• Date and follow-up plan for a return visit, and discharge plan.

3. Health Management and Continuity of Care
Health management and continuity of care should be clearly reflected in the home-care medical record and the following should be documented (at minimum):

• Evidence that changes in medical and/or mental condition were reported to the physician and appropriate interventions occurred
• Evaluation of progress toward short- and long-term goal attainment (redefining of goals, if applicable)
• A record of scheduled physician appointments
• Evidence of interdisciplinary action between all professional disciplines involved in the member’s care.
• Appropriate follow-up on diagnostic studies
• Records of communication with the member regarding care, treatment, and services (for example, telephone calls or email), if applicable
• Member-generated information (for example, information entered into the record should include statements from the patient and/or family)

4. Discharge Summary
Discharge summaries should include the following:

• A description of the member’s medical and mental status
• Evidence of achieved goals
• Follow-up instructions were given to the member
• Disposition of the member
• Evidence that the discharge summary was sent to the Primary Care Physician and/or the specialist within seven days of the last visit.

Following these guidelines will help to ensure your documentation is comprehensive and encompasses the current skilled visit regulatory guidelines.

Learn more about how your agency can thrive in an ever-changing environment by visiting our Home Care page.

Do you have questions about documentation or other clinical challenges? Call Richter’s clinical consultants at 866-806-0799 to schedule a free consultation.

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