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 assessment.
• 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 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)
  
  
  

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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 were initiated
• Evaluation of progress toward short- and long-term goal attainment (update the goal to reflect the progress, if appropriate)
• A record of scheduled physician appointments which should be discussed during the visit
• Evidence of interdisciplinary action among all professional disciplines involved in the member’s care (e.g., therapy, nursing, social services, aides)
• Appropriate follow-up on diagnostic studies. In this regard, ensure that the physician has been notified and that new orders have been obtained, if appropriate
• 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; this should paint a comprehensive picture for the person reading it
• Evidence of achieved goals; remember that goals must be measurable
• Follow-up instructions given to the member; you should also review and discuss any follow-up prior to the end of the visit
• Evidence that the discharge summary was sent to the primary care physician and/or the specialist within seven days of last visit (remember to document this in the record)

Following these guidelines will help to ensure your home helath agency's documentation is comprehensive and encompasses the current skilled visit regulatory guidelines.

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