For many clinicians in home health care, documentation can often be the least favorite aspect of their work. However, it is undeniably the most crucial. Whether you're a seasoned professional or new to home health care, charting and documenting accurately can be a challenge, particularly for those who are just starting out. 

In this blog, we share some valuable tips to help you improve your documentation. These tips will help you overcome the hurdles and ensure that your documentation is comprehensive, accurate, and meets the highest standards of care.

Here are 9 tips to help you improve your home health documentation

1. In home health, "If it is not written, it is not done." It is crucial to document even the small details, such as the reason for not being able to perform a certain task that was in the Plan of Care.

Proper documentation allows other healthcare professionals to understand the patient's condition accurately and make informed decisions regarding their treatment. That’s why it’s important to always document progress (or lack of progress) toward goals as they are stated in the plan of care. This provides valuable insights into the patient's progress and any potential barriers they may be facing. 

2. When planning visits for the day, always check your patients' charts and review the visit frequency. It will save you time, effort, and headaches from reconciling and correcting them later on.

Getting familiar with each patient's information in advance, such as the frequency of visits required, specific instructions or care plans, and any recent changes in the patient's condition, not only helps with workload management but also minimizes the chances of missing important details or encountering unexpected challenges during visits.

3. Every single medication, even O2 and off-market medications, must be documented, listed, and updated in the patient's medication profile. It's easy to document them on your visit note, but it's also very easy to forget to reconcile them with the medication profile.

Consistently documenting and updating the medication profile minimizes the risk of medication errors, helps identify potential interactions or duplications, and facilitates effective communication with other members of the healthcare team. 

4. To avoid overlapping visit times when documenting, use your smartphone's screenshot feature to kind of "clock in" and "clock out." When you do your documentation, you have images with the time to go back to. No smartphone? Small sticky notes will do the trick! Write the time you started your visit, then the time you end your visit and stick them to your patient's file folder or your notepad.

When unable to complete documentation at the point of care,this method can be especially useful when you have multiple visits scheduled close together, preventing any confusion or overlap in documenting your visits. It’s a simple yet effective solution for maintaining accurate and organized records, reducing the chances of errors or discrepancies in the documentation process.

5. Care coordination is paramount. There should be no conflicting assessments among clinicians on the case. We've seen cases with conflicting vitals from back-to-back visits, administration of incorrect insulin dosages, and even inconsistent reasons for same day missed visits.

When multiple clinicians are involved in a patient's care, clear and consistent communication and seamless collaboration are important. Conflicting assessments, such as inconsistent vital signs or medication administration, can lead to confusion, compromised patient care, and potential harm.

6. Reviewing your own documentation before submitting may take extra time, but it will save you more time later from the back-and-forth with QA. It will save you from inconsistencies like indicating a patient is homebound in the checkbox, but have a narrative that hints the patient may not be homebound. Another example is stating that, "vital signs are stable" even when there is a v/s that's out of parameter.

Investing time in reviewing your notes initially requires additional effort, but this practice is worth it. This proactive approach helps identify and correct any inconsistencies or errors, ensuring that the information is clear, concise, and aligns with the patient's actual condition and care plan. 

6. On therapy reevaluations, be conscious of changes in the plan of treatment. A minor adjustment in the exercises or deviation from the original frequency will be considered a "change in the POC." Remember that any change will require the doctor's approval and signature.

Even seemingly minor adjustments in exercises or deviations from the original frequency can be considered changes in the Plan of Care (POC). It is important to make sure that any changes are properly documented, approved, and signed by the physician. 

This not only ensures compliance but also promotes patient safety, continuity of care, and effective communication between the therapy team and other healthcare providers involved in the patient's treatment.

7. Although it may vary from agency to agency policy, it is best practice to take and document pre- and post-exercise vitals, especially the BP of patients with hypertension or acute or late CVA, for example.

Measuring and documenting these vital signs can help you identify any significant changes or discrepancies that may require immediate attention or an adjustment of the exercise program. 

8. Medications administered by the clinician during the visit must be completely documented, to include the medication name, dosage, route, and site.

Adhering to thorough medication documentation practices contributes to improved patient outcomes, minimizes medication errors, and ensures optimal delivery of care.

Home health documentation may seem like a tricky and tedious process, but by practicing these tips, you’ll soon realize that it can be simple. With the right process, tools, and support, you’ll be able to improve your documentation in no time.

For over 8 years, QAnnovate has been supporting clinicians and home health agencies through specialized clinical documentation quality assurance - a solution to help home health agencies deliver the highest quality of care to their patients. Contact us today for a FREE trial. 

Related blogs:

5 Tips for Accurate Home Health Care Documentation

Home Health Documentation QA: Why It Matter