12 C’s of home health care clinical documentation
These are all C’ritical to your success
By Michelle Boasten
Worried about getting your documentation right? If you get these dozen items right, you will have a lot less to worry about.
1. Clinical Note.
Each home care visit by any discipline requires an individual record of the visit. It must include the client’s full name. The state surveyors are looking for the note and if it’s missing, it’s as good as not being done. The clinical note itself is the only evidence that a billable home care visit has taken place. The clinical note is the legal accounting and record of the visitation made between the home health care professional and the client.
The note needs to be legible. If the surveyors cannot read the note, it is not as bad as if it were not there at all, but it’s the next worse thing to not begin there. If the field staff have illegible handwriting, then it should be printed.
The content of a note is what was done in the home — what happened on the visit. Content are things like skills, tasks, duties, patient responses, etc. Certain skills in home care are not reimbursable. Therefore, you need to be sure that what was done is worthy of being billed.
Each note must be compliant with the visit pattern established on the doctor’s orders. Best known to home care professionals as the 485 or plan of care, an established visit pattern like 2wk8 means two visits every week for eight weeks. If one is missing or if one is added, it must be justified and documented. This justification should properly be handled on a telephone order. This order needs to be signed by the physician.
The message each discipline sends must be congruent with the other disciplines. If the aide documents the patient is walking and the nurse documents that the client is bed-bound, there’s a problem. This is a frequent problem found by surveyors. It is important that everyone be on the same page. When reviewing a home care record, it is very important to assess all notes from all disciplines in sequential order.
Every change must be documented. Medicare wants to see changes. Medicare does not pay for custodial care only or even for maintenance visits. Be sure to look for the progress of the client. Any change, whether progressing or digressing, needs to be clearly documented.
The initial paperwork includes a referral and new orders. The 485 is generally established within 48 hours of the initial assessment. Make sure that everything else that follows throughout the clinical documentation makes sense. Let’s say you start to find blood sugar reports, but there are no orders; and furthermore, there is no diagnosis of diabetes anywhere. This is an obvious clinical contradiction. Likewise, say that the aide is doing tub baths, but the care plan clearly states bed baths. This is a contradiction. Contradictions are red flags to surveyors.
8. Continuity and Consistency of Care, NOT the Caregiver.
Many times in home care you would love to have continuity of the caregiver, meaning the same caregiver for each visit. But this can be nearly impossible as an agency grows. Medicare isn’t looking for consistency of caregivers; it is looking for continuity of care. That means that every caregiver delivers the same type of care. That means that Nurse Maggie, Nurse Ann, and Nurse Nancy all deliver the insulin in the same way or that they conduct their cardiac assessments in the same way. This is true in an inpatient setting, and it should also hold true in a home care environment.
9. Complaints. Surveyors want to see the complaints of the clients and how you follow up with them. Each agency should have grievance procedures and protocols. If there is a complaint or problem, documentation and follow-through needs to be evident throughout the documentation.
Your clients are introduced to the surveyors by and through your words. Bring your clients to life by quoting them in your notes. What comments do they make? Jot down what they say about their care and about the services you provide. Remember that your notes have to justify payment.
11. Conflicts and Confrontations.
If anything is not right, if anything does not look right, if there’s a problem, it needs to be on a note, case conference, or incident report. Again, each agency should have a protocol and procedure on how to handle problem or incident reports.
Each note needs to have a complete end. The note is a legal record and accounting of what happened and when. It must include the worker’s signature, date, visit start time and visit end time.
[Michelle Boasten, a consultant for FBE Service Network Home Care Consultants, specializes in clinical and regulatory home care issues. She is the clinical consultant to Dial-n-Document, a home care clinical documentation program. She can be reached at (330) 253-6368.]