Documentation in Home Care

Compliance with Medicare regulations is of utmost importance to stay in home health care. It isn't enough to make a visit and do your assessment and check a few boxes in a note. I tell nurses that 50% of their time is spent on the bedside and the other 50% is charting. Checking boxes and charting that you have assessed the patient is also not enough. Medicare wants to see nurses doing something about their assessment findings. If you assess that the patient is having a pain level of 7/10 and that is all you charted about then your work is unfinished and your visit will not be paid by Medicare. You must chart that you assessed why is the patient's pain a 7, where is the pain, why is the patient having pain, what made it worse, what makes it better, what was the patient's pain like a few hours ago,  what has been contributing to it (emotional issues?), medications and other treatment being used, what are the teachings you have provided, what do you want to do about the pain/what is your plan?, are you going to report it to the doctor? etc. THEN, all these have to be documented. When you can paint a good picture of what is going on with the patient and what interventions and teachings you have provided, then Medicare will see that your visit is worth the reimbursement. Medicare saved a few hundred dollars for the home health visit because this would have cost them more if the patient went to the emergency room.

Why Home Care Nursing

Home care nursing is one of the many settings where a nurse provides patient care. It is unique in a way because the patient is in his/her natural surrounding whereas the nurse is the stranger coming in to the place where the patient resides. This could be in the home, assisted living facility or senior housing. Research shows that patients have faster recovery from acute medical conditions if they are in their familiar surroundings. Being able to receive medical care in the home is a wonderful benefit from Medicare and other health care insurance (private, med-advantage, etc.).
Home care nursing has several advantages over hospital nursing. First, is flexibility with work schedule. You can, for the most part schedule visits around your home obligations. Being able to send children off to school and be home at the same time the kids come home from school is a wonderful benefit. You can choose days and hours you want to work as well as choose not to work on weekends except for occasional weekend on-call rotation. Second, is the ability to focus on one patient at a time. At each patient visit, you have an undivided attention thus giving the patient the opportunity to receive thorough assessment, teaching and emotional support. Third, autonomy and the ability to use critical thinking skills and good decisions in carrying out best practice in nursing. Autonomy however can be scary for those who are new in nursing or new in home health. Whereas in the hospital you have all the equipments and other clinicians to assist you with questions and during emergencies, home health has none. None in the sense that these are not physically there at the patient's home. However, support from other home health staff and supervisor is just a phone call away. In an emergency, 911 is also a phone call away. Doctors are also a phone call away but because of their busy practice it might take 24-48 hours before your call is returned. Again being able to make good decisions based on clinical knowledge and evidence-based practice is critical in the success of a home care nurse.