The regulations for documenting home care skilled service have been changing so rapidly that it is difficult to know what is required from one day to the next. When you are documenting for skilled services it is important to be thorough, yet succinct. Let’s break this down into some manageable pieces and discuss the requirements for each.
All care should be documented in the patient’s home care medical record and should include the following:
Initial plan of care.
Updated plan of care.
Intermittent physician orders.
For each skilled nursing and/or ancillary service visit, a progress note should be present in the patient’s medical record within twenty-four (24) business hours of the visit. The progress note should support the plan of care and include accurate and specific descriptions of the skilled visit.
With that in mind, the skilled progress note should include at a minimum all of the following:
Current medical condition, including diagnoses related to skilled care
Current mental status, including if there have been any recent changes
Homebound status (note: this can be waived during the PHE)
Physician-ordered care given to the member during the visit—specifically, what was the skilled service that was performed
Follow-up on previously identified problems
New onset of symptoms, including a new diagnosis if the patient has been seen by a physician
Teaching and training activities done with the member, caregiver and/or significant other which includes, but is not limited to, education regarding disease process, as applicable (documented from start of care date)
Response, capability and accuracy of member, caregiver and/or significant other to perform the required care as taught
Outcome of interventions, including measurable information
Date and time that services were provided (note: always make sure this is legible)
Signature/title of person providing services (note: always make sure this is legible)
Date and follow-up plan for return visit (note: always communicate this with the patient and/or caregiver)
Discharge plan (note: this should be discussed during every visit with the patient and/or caregiver)