Documentation Basics for Home Health

It is easy to become complacent about documentation. As nurses, we must always be trying to raise the bar on ourselves and on each other to stay professional and above all, to show that we are using best practice and evidence based techniques in every aspect of our career.

However, in home health, it is very easy to succumb to the least amount of charting; to live by the “chart by exception” rule and not give ourselves the credit we deserve as professional nurses. What happens then? We come off looking as if we do not care, we do not know enough to write even the basic nursing care and as if we are not willing to raise the bar on ourselves, just to get away with the least amount of work effort.

That is embarrassing and an affront to your nursing profession. Medicare rules and regulations changed drastically in 2000 and have continued to change since that time. Our documentation must reflect the changes and the growth of knowledge expected by Medicare for all our home health patients. We should not have to be told by Medicare to change; it should be our desire to change, to flourish as nurses and to learn at every opportunity.

However, as it is with many things, sometimes a reminder of the expectations and direction are all that is needed to get the ball of change rolling. That is what we will be talking about today.

The Outcome and Assessment Information Set

In home health, the Oasis (Outcome and Assessment Information Set) is done on admit, resume care, recertification’s, significant changes and on discharge. From the admit and the recert OASIS is created the physicians Plan of Care called the 485. This is the tool that must be used at every home health visit when completing your nurse’s note. This is your physician order for care delivered in the home. Your documentation must show that you are aware of the physician orders, are following the physician orders and that you are updating the physician, the patient and the family on all changes related to the patient that are not on the physician orders.

Without the 485, you are going blind into a patient’s home and delivering care without any idea of what the physician is expecting you to do and to know. That is not the way you want to deliver your professional care! In order for the office staff to generate that hard copy of your physician order, the 485, you must get the OASIS, especially the admit but all types of this tool, completed and turned into your office within a timely fashion. Every home health office has different expectations, however, most are expecting that OASIS to be returned to the office within a 24 hour window.

Seven Day Window

The reason for this is that the information must be inserted into the computer and locked and sent to Medicare, or the HMO or private insurance company, within a seven-day window. It does not mean seven working days. It means seven days from the start of care. This is not unreasonable. If you were working in a hospital and had an admission, all your paperwork for that admission must be completed by the end of your shift. Home health gives a 24-hour window for completion.

All parts of the OASIS must be thoroughly scrutinized by an objective set of eyes. Usually this means a clinical supervisor or case manager who goes over all the information from the referral and the OASIS with a fine toothcomb. The result of this, many times, is that you receive your work back with enough yellow stickey’s on it, for it to take wings and fly. None of the corrections is meant to insult your intelligence or degrade you as a nurse. It is meant for you to take a better look at the information you have provided and give a succinct picture of that patient and that patients needs for home health.

Every bit of information, sometimes redundant, must be completed on the OASIS or Medicare or the HMO or the private insurance company could send it back without a word of explanation except that it is incomplete. A refusal of payment is not out of the question either; especially if the forthcoming information is so sketchy and vague, that it does not show good reason for our services.

Your Daily Visit Notes

The following documentation, your everyday nurse visit notes, must then reflect the physician orders found on the OASIS. The 485 will tell you what to write in fact it will write your nurses note for you if you use it as the tool it is intended to be. Every nurse note in home health must stand-alone. Every nurse note must reflect the assessment, the performance, the instruction, the goals and the progress toward goals for your patient. That means you must have that 485 in your hand in order to see your patient, carry out the physician orders, do all the assessments expected by the physician and instruct your patient on what you are doing in order to give them the best possible care.

Is this not what we, as professional nurses, want for our patient’s?

Are we not proud of the fact that with our extensive skills base, we can go into any patients home and deliver the most competent care in an autonomous fashion, make critical care decisions that reflect our nursing knowledge and help the lives of our patients in a way no other nursing field is able to do? We should be proud enough, then, to deliver the most up to date documentation to reflect that care.

Many times, it is simply a matter of not giving ourselves the credit we deserve. We walk into a patents home, we are talking and assessing, and teaching the entire time but we never put down on our nurse note all that came out of our mouths. Well, what is that old saying? Oh, I know, “If it was not documented, it was not done.” If your nurse note, all by itself, were to be held up in a court of law, say in a decade, would you be able to tell, from that one note, exactly what you accomplished on that one visit?

Your Boss Looking At Your Work

That is the problem with home health notes. They are often held up one at a time for scrutiny and found lacking. The first scrutiny comes from your clinical supervisor who is looking at your daily nurse’s note. That nurse is looking at the 485 on the screen in front of her or from the patient chart. First, it is given a quick scan, just looking for any holes, things that were missed because you were in a hurry. Then every piece of that note is looked at to be sure it shows your awareness of the 485, the patient and that you accomplished everything in that visit that was expected by the physician.

Parts of the 485

The 485 has different fields on it that correspond to everything that is pertinent about that patient. It contains the demographics, the insurance, the supplies, the homebound status, the functional limitations, the assessments, skills, and instructions the nurse will be providing and the goals we want that patient to accomplish within a 60-day period. Fields 18, 21 and 22 are the ones we use the most to deliver care and to write every nurses note. Field 18 deals with homebound status and functional limitations. These must match on your nurse’s note or you need to document how they have changed. Perhaps therapy has progressed the patient from a walker to a cane. Your nurse note needs to reflect that change and you must write every time that therapy has progressed patient. The 485 you carry around from visit to visit should be so dog-eared by the time of discharge you can barely read it. It should have all the new and changed orders stapled to it. You should be able to put your hands on it without a second’s hesitation and see your patient in your mind’s eye. Your clinical supervisor should be able to pick up any one of your daily visit notes and also see your patient in their minds eye.

Field 21 is what you are to do, every visit, for that patient. Of course, if for example there is wound care you need the most current physician order related to that wound care and it must be verbatim. You must deliver the wound care or any skill precisely the way the physician has ordered it by signing the 485. Otherwise, we are delivering care without a physician order. Even if all you change is kling instead of kerlix, that is an error. Where it gets really dicey is with complicated patients, with wounds, IV therapy, post op, therapy, polypharmacy, and therapy. Without that 485 in your hands you are not delivering safe care with best practice standards.

Discrepancies Found in Daily Nurse’s Note’s

If the 485 has a diet of low sodium and you write cardiac, it will come back to you. If you write taught on disease process without any supporting documentation, it will come back to you. If you do not write a measurable progress of goals taken from field 22 on your 485, it will come back o you. If you said you drew labs and did not spell out every step, it will come back to you. If you gave a cyancobalamine injection and did not write down the lot number and the expiration date, it will come back to you. If one portion states patient had a pulse oximetry taken and the 485 does not give a physician order for pulse oximetry, it will come back to you. If you forget to remark on how much recall the patient had from previous visits, it will come back to you. If you write that you instructed patient on IV therapy without stating every step you taught, it will come back o you. If you state return demonstration received without writing what was demonstrated, yes it will come back to you. Of course, if you write about sending the patient to the physician office or to the hospital emergency room, that will be scrutinized closely to make sure you used best practice, called the physician, notified the emergency room nurse of patient coming to them, called the caregiver, and completed all forms that go with notifying all other disciplines of your actions.

But WHY?

The reason for this extremely meticulous documentation is, of course, that every nurse note must stand-alone. It must be able to be picked up years, months, or days from now and see exactly what and how something was done in that patients home. Most of all, what is being looked for in every nurse’s note is your knowledge of that 485 and the physician expectations for home health care.

What is being done in every home health agency is not being made up to make the field staff lives miserable. Home health agencies are being held responsible by Medicare, the HMO, or the private insurance company accountable for delivering exceptional care. You clinical supervisor is being held accountable for their job description and they, in turn, are holding you, as field staff, accountable for the care you are delivering. If you are being paid by the visit, by the hour or by salary, the expectations remain the same. Provide the care to the patient that the physician ordered and be responsible for everything that you do.

As home health nurses, we are the eyes for the physician. We must use our mouths to keep the physician updated on what is happening with the patient. We must deliver the quality of care the patient deserves. We must continue to learn every day and to grow as nurses every day in order to meet the needs of our patients. It is our pleasure to do so. We are service-oriented people who want only the best for our patients and we want to be proud of the care we deliver in the home health setting.

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Comments 22 comments

dinesh c bhatt profile image

dinesh c bhatt 6 years ago from India (Noida)


Great Hub, keep on writing !!

RNMSN profile image

RNMSN 6 years ago from Tucson, Az Author

thank you dinesh!

bayoulady profile image

bayoulady 6 years ago from Northern Louisiana,USA

Great professional hub, well written and useful!

RNMSN profile image

RNMSN 6 years ago from Tucson, Az Author

thank you j/bayou!! you can tell where my mind set is now,eh? love to you, barbara b

bayoulady profile image

bayoulady 6 years ago from Northern Louisiana,USA

I CAN tell you are BACK!!!hugs!

MartieCoetser profile image

MartieCoetser 6 years ago from South Africa

I’m pro-organized structures like this. This is the professional way of rendering services and to the benefit of all involved. RNMSN, please go check my hub called “My favorite hubbers”.

bayoulady profile image

bayoulady 6 years ago from Northern Louisiana,USA

Yeah b, I put you down,too!(on a forum about favorite hubbers) Hugs!

RNMSN profile image

RNMSN 6 years ago from Tucson, Az Author

yea jackie I am back YES!! love you girl hows the rocking chair days treating you not having to teach!

well my goodness Martie and bayoujackielady thank you both so very much!! I am honoured and I treasure it!!love to you both barbara

Stoneage2010 profile image

Stoneage2010 6 years ago

Hi :-)

Wonderful Hub ,loved it!

RNMSN profile image

RNMSN 6 years ago from Tucson, Az Author

thank you sotneage2010!! I am giving this as an inservice in three weeks here is hoping the homehealth nurses are as receptive as you!! don't we all just loooooove change? love to you barbara

CMCastro profile image

CMCastro 6 years ago from Baltimore,MD USA

The Nursing Professions are getting more challenging, now aren't they?!

RNMSN profile image

RNMSN 6 years ago from Tucson, Az Author

yes we have certainly matured over the last three decades and more is asked of us than ever before...its up to us to keep the bar as high as possible for all the newbies don't you think? love to you thank you for your comment barbara b

Happyboomernurse profile image

Happyboomernurse 6 years ago from South Carolina

GREAT hub on documentation and why good documentation is so vital. I left homecare shortly after OASIS was implemented so things are done very differently now and I can see, after reading this article, why homecare documentation has to be submitted so quickly nowadays.

Even before OASIS all of the above needed to be documented but it was mainly done on the initial 485, the recerts and on a daily basis, the careplans. Good careplans reflected everything you've written about here and matched what was on the 485.

I voted this hub up, useful and awesome.

RNMSN profile image

RNMSN 6 years ago from Tucson, Az Author

thank you happybomernurse!!! wish you could be here with me tues the 11th

Happyboomernurse profile image

Happyboomernurse 6 years ago from South Carolina

My thoughts and prayers are with you.

RNMSN profile image

RNMSN 6 years ago from Tucson, Az Author

it will be all right/I am not going to apologize/not as a sarcatic smiling southerner nor as a cowed supervisor/I have prayed and talked and tought and I am going to just keep on doing as my as I can for the ones who want my help and let the rest go/just like you said...I am doing worth while work even with the drama/Im keeping my head down and the work going through...the survey that is way overdue will likely tell the tale eh?

Happyboomernurse profile image

Happyboomernurse 6 years ago from South Carolina

Indeed it should. God bless your dedicated soul.

RNMSN profile image

RNMSN 6 years ago from Tucson, Az Author

thank you friend, wish you were here with me

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John G Blanchard 4 years ago

This is a fine article, but completely doesn't address the problem of computerized systems. I have been working at a single HH company for over 3 years, and I am more than competent with computers. I have found many problems dealing with the computerization of charts; in our case, the system we use basically transfers our old paper forms to a computerized version but doesn't usefully help us track orders, patient progress across visits, vital signs, etc. etc. And since our boss doesn't pay for wireless access (and the nurses didn't use them when he did), essentially nobody checks the chart while with a patient. Well, I do, but it's so hard to do it with our system and usually fruitless because so many notes haven't been turned in, I don't blame nurses for not checking.

I am presently looking around for some company that has a good computerized system in the LA area.

RNMSN profile image

RNMSN 4 years ago from Tucson, Az Author

Good Morning John! I know how you feel! my research paper for grad school was on the effectiveness of laptops in the home health setting :) lol

we found/not surprisingly/that it did not improve our work...made it look pretty though...never did see "your handwriting..." on my evals anymore!

but when all we had were handwritten notes and thick manila folders of info on our patients and our cell phones to call each other of course...our continuity of care was actually better! keep looking though and let me know which system you like the best! know what else I found? that when HH co get the laptops...they expect nurses to see more patients in their day and that of course makes quality of care go down the tubes too

Compliance Doctor profile image

Compliance Doctor 3 years ago from Los Angeles, California

I am sorry to say that I do not agree with the overall suggestive declarative in this article. The article implies that nursing should want to comply with these ridiculous step by step, let's count your competency, write every thing you think and do for the patient theory or concept. I believe you could not be any further from the actual truth. Here are my thoughts:

1. Nursing has never received the professional accolades that it should demand and therefore, the respect for nursing as a profession has never been as trusted as it should in the care and delivery of patient care. There are many reasons why, but for starters, it is the nursing shortages with the US states that has compromised our profession. We allow nursing students/professionals to come into the US and some states allow them to take the state boards or even apply for reciprocity and then issue a license. Patient lives have been compromised to the point of death because of the diverse language barriers that exists in the various health care settings across the US map. Thus, distrust is built.

2. The increase in the amount of monies being funded to these shady home health agencies across the map, well that goes to speak to its own. But, the end result is a medicare OASIS program that requires everything be accounted for in order to achieve compliancy with monies being distributed and advanced into the checking accounts of many crooks, fraudulent medicare whores (excuse my specifics in language).

The whole theory that nursing should document every step in their thought process of delivering care is ass backwards. Physicians do not have to document every step they process in order to come up with a diagnosis. Then why would we? The push to a nursing "charting by the exception" should have already been the standard of today, though it is not. By charting by the exception and not the rule, you should have more time at the bedside for nursing care versus being held at the nursing station charting all shift the ridiculous facts of "within normal limits, patient is afebrile all shift, +bs x 4 quadrants, and the list goes on!". Is it not better to tell the medical record when the patient became febrile and what you did to resolve that spike in fever? I think so as it not maters a spec of ones energy to chart the patient was afebrile. My assumption is that afebrile is the normal, the exception is the spike or febrile status. Sure, some say it's CYA theory; well this is all bull crap. Is it is our profession to cover our butts doing the right thing? I don't see the problem charting what was done when and only when there was actionable care delivered. But to imply that we do this for the good of the patient, it is entirely undocumented or proven that the care is better when all is charted. What is documented is that the nursing care provided is less of the quality standard than it is when the nurse is where she/he should be for the duration of the shift and that is with their patients doing patient care. God Rest Florence Nightingales soul, how would she ever have been able to live in today's world of nursing not at the bedside but at the nursing station afar from her patient?

RNMSN profile image

RNMSN 3 years ago from Tucson, Az Author

This hub is not about nursing home documentation but rather home health. I understand your frustration with nursing in general, but it is up to each individual nurse to decide if they can continue to give quality patient care as well as follow all the rules and regulations. Whether it is with an OASIS for home health or an MDS in the nursing home, nurses in this country are required to follow Medicare rules and regulations for the safety of their patients. It is not about covering your anything, it is about having a record of all your good work. Nurses are the eyes,ears,hands and hearts of healthcare, take that thought with you every day and it will not matter to you what anyone else is doing, your work will stand alone and stand the test of time.

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