Home Health Care Documentation

The home health care industry continues to grow in our society for a number of reasons. Limitations in coverage within the acute care setting are a major cause for the growth, as is the desire patients have to be cared for in their home rather than in a health care facility.

Documentation in the home health care system has different implications than in other areas of nursing. The primary difference is the nature of the home setting, which dictates that a narrower scope of people (e.g., patient, family, direct health care provider) witness the majority of care. Home health care requires that the entire health care team work closely together. The documentation of care must be accurate and complete so that all members of the team are able to ascertain what care is rendered in the home. In addition, the documentation provides both the quality control and the justification for reimbursement from Medicare, Medicaid, or private insurance companies. Nurses have to document all their services for payment (e.g., direct skilled care, patient instructions, skilled observations, and evaluation visits). The nurse is the pivotal person in the documentation of the delivery of home health care.

Home health care documentation has several components that the nurse must consider. Medicare, Medicaid, and private insurance typically have similar requirements in regard to documentation. The patient’s eligibility for homecare must be thoroughly assessed and documented. In addition, the nurse must document in detail any procedures, treatments, or medications administered and response to these interventions. Another important aspect of health care documentation is noting any patient education and demonstration of learning. Home health documentation must also reflect coordination of services by all members of the health care team and evidence of compliance with regulations (Kimball, 2010). Home health care is discussed in more detail in Chapter 36.