Documentation for home health care

Documentation for home health care

In an age where public and private insurers are carefully watching every penny spent, health care providers have to document patient care very carefully. Private insurance companies, , ask for significant detail when they review patient cases for reimbursement.

  • Evaluation
    • When beginning with any patient, a clinician must begin with a complete assessment and evaluation of the patient. This includes more than just examining the condition for which the patient is receiving treatment, but a thorough review of the patient’s entire functioning and health status. Clinicians must record all details of their evaluations, clearly establishing the patient’s condition upon start of treatment. This will become a benchmark for tracking treatment progress over the 60 day period during which Medical Insurance will fund an approved home health patient.
  • Plan of Care
    • Patients often see more than one type of a clinician. It may be that a patient recovering from a stroke sees a nurse, a physical therapist and an occupational therapist. Each clinician must develop a thorough plan of care delineating a clinical route for getting the patient from their starting point to a higher level of health and functionality. Plans of care include goals, treatment types and measures for outcomes. Medical insurers will insist on seeing each plan of care for each patient before reimbursing for services.
  • Progress
    • Medical Insurance pays for a patient’s progress or at minimum, maintenance. As nurses and therapists deliver services, they must clearly denote the care they’ve given and how it relates to the patient’s plan of care. In addition, treatment notes should indicate the impact of the intervention or treatment on the patient’s overall condition. For example, if a physical therapist is visiting a Medicare patient recovering from a total hip replacement, the therapist should note the exercises performed, how the therapist’s skill and supervision were involved, the goal of the exercise, how the treatment relates to the plan of care and what progress the therapist has noted since last visit.
  • Specificity
    • Charting needs to be clear, specific and measurable. Notes must be written not just for a clinician to remember a patient’s case or to share information with another clinician working on a patient — but for a insurance reviewer to understand the necessity and progression of the patient’s course of treatment. Therefore, instead of writing a goal to say something like, “Use therapeutic weights to restore upper arm strength and functioning,” a goal should have measurable elements like, “Patient should regain 70 percent arm strength to be able to lift herself off sofa with zero assist.” A plan of care treatment method might read, “Patient will lift therapeutic dumbbells beginning at three pound weight and increasing steadily per patient progress and tolerance.
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