Across the healthcare industry, documentation has always been the most critical puzzle piece to compliance and reimbursement. The home health sector is no exception to this rule. Over the years, the Centers for Medicare and Medicaid Services have continuously rolled out surveys and audits resulting in numerous claim denials which are basically synonymous to lost revenues among home health agencies. That is why the importance of effective home health documentation cannot be stressed more. To help you navigate this seemingly simple and yet tricky and tedious process, we listed three (3) useful tips that you need to keep in mind in order to have effective home health documentation.

1.      Put yourself in the reviewer’s shoes.

You should consider that the MAC or surveyor does not have the depth of knowledge and expertise you or your agency’s disciplines have in terms of care provision. Given this, your care documentation must reflect clear and objective data on the patient’s needs and problems, the care services you provided, and the interventions done towards achieving the goals that were identified. You must be able to communicate your patient’s status and progress to any kind of reader, whether that be your manager or a surveyor.

2.      Paint a complete picture of your patient’s story.

When you read your documentation, it should be able to paint a full picture of your home health patient’s story with no missing links nor shortcuts. Make sure that every step of the way is recorded, even calls made within your team and with the physician. For example, if the patient has a change in their condition, your documentation should be 

able to tell what the findings were, what interventions were done, and what was the patient’s response. For every visit, an assessment, care planning, intervention, and evaluation must be done. Expectations from the patient, their family and caregivers and education provided to these stakeholders should also be recorded.

3.      Comply with quality and regulatory standards.

This might be the hardest step of all as there needs to be a clear understanding of what CMS policies and regulations are and how they relate to your day-to-day tasks. It is important that your agency has a QAPI program as clinical documentation and QAPI works together to ensure that you are survey ready with your documentation. In addition, you must be updated on the current industry policies so that you are kept abreast of any changes that might affect your agency’s operations.

Data Soft Logic, as Your Intelligent Care Partner, is here to support you by being in the lookout for the latest industry happenings. As such, we would like to invite you to the Successful Home Health Agency Management and Effective Documentation Strategies seminar on November 18, – November 20, 2021 in Hampton Inn Tropicana, Las Vegas, Nevada. Get to spend three days learning the techniques to minimize your stress and have a successful survey as well as the strategies for effective documentation in all areas of the clinical record. Find out too, how we can help you apply your takeaways from the seminar through Home Health Centre Ultra, our intelligent software solution designed for home health care.

Register at NJ Center for Continuing Education website for the seminar and schedule a demo with us now.