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.