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.
Best Practices for Documenting Home Care Skilled Services
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
Current mental 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 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
Date and time that services were provided
Signature/title of person providing services
Date and follow-up plan for return visit
Health management and continuity of care should be clearly reflected in the home care medical record and at least the following should be documented:
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)
Discharge summaries should include:
A description of the member’s medical and mental status.
Evidence of achieved goals.
Follow-up instructions 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 (7) days of last visit.
Following these guidelines will help to ensure your documentation is comprehensive and encompasses the current skilled visit regulatory guidelines.
Jennifer Leatherbarrow RN, BSN, RAC-CT-QCP, CIC is the Senior Clinical Consultant at Richter Healthcare Consultants. She is a passionate writer and a speaker at both state and national levels. Jennifer has been working in post-acute care for over 20 years. She is an avid proponent of education and providing those on the front lines of healthcare the tools they need to succeed.
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