Perfecting Home Health Documentation

Documentation That Stands Alone

Starting a new job; even if it is in the same field; is always difficult. The people in the office will test the newcomer. The field staff will see what they can get away with, the boss will see how much pressure you can take before you run screaming for the hills.

The thing that is constant about home health is the astronomical amount of paperwork that is required in order to pass muster for the government.

As it is, every home health agency worth its salt must be Medicare certified; regardless of how many HMO or different insurances they accept, they all must abide by Medicare rules and regulations.

This means that even though you (hope) know that nothing but Medicare charts will be audited by the government you must treat every patient as if they are just plain Medicare. The reason for this is clear.

Medicare has the most stringent rules and regulations about the care you deliver and the documentation you submit to support the justification of that care, The moment you let your staff become complacent about their documentation that is when you better be looking over your shoulder, because the auditor or the surveyor or the consultants will be on their way to your office!

The longer you let the sloppy documentation go on, the harder it will be to get the field nurses back into the habit of charting what they are actually doing and saying. The longer you allow cookie cutter documentation to go on the more assured you can be that your nurses are going into patients homes, shaking their patients hands, asking how their children are and walking back out again!

Because, due to the fact that most home health agencies pay by the visit instead of by the hour, most home health nurses want to do as many patients as possible in as small a radius as possible in order to make the most money as possible. It is these types of nurses that give home health a bad name. It is these types of agencies that want as many visits per month, therefore as much money as possible that causes the bad reputation of home health agencies across the board. Just as it was in the 1980 and 1990's, with the home health agencies being paid by the visit, they made millions by seeing the same patients for decades, pre-filling med boxes and syringes and now, with PPS, they are still finding ways to make the most money in as short amount of time as possible!

And it is still nurses, old ones, like myself, who feel nursing is a craft, that believes the more we learn the more we will be able to give our patients, that the better we document the better our skills will become, that the more skills we learn the more we will be able to teach our patients; that the more our patients learn, the less likely they are to end up back in the hospital!

Whew! Long run on sentence eh?

All of this to lead you up to the fact that I, mean ole nurse, am a clinical supervisor and I have been told to gently roll over the nurses documentation and to gently lead them into the correct way back to the light.

Today, the darkness fell on this clinical supervisor.

In very loud, dramatic, in the open way of nurses this nurse had another nurse adamantly refuse to follow the instructions that had been put onto their notes. This nurse even spoon-fed the correct information to write on the nurse note!

The nurse said loudly and on the way out of the door "I won’t do it and you better back off because I won’t do that and if you put any more notes back into my box I will kill you!"

The fact that the nurse is very dramatic and flamboyant aside, I knew it was not a heartfelt threat. Still, I checked to be sure all my tires were intact before I drove home!

Moreover, if I turn up murdered all of you are witnesses of course lol

The most discouraging thing is this nurse is not the only nurse who documents in this manner. The nurse notes are all alike...their favorite blurb as far as instructions go is "instructed on diet, nutrition, sign of infection and CP distress." What does that mean EXACTLY?

If it isn't written...

That means that anyone, nurse or not, that feels they are superior, that they do not need instruction or are unwilling to raise the bar on themselves and to hone their craft to the ninth degree is stagnant.

In addition, stagnant means they are stuck. They are not going anywhere. They will never excel more than they already are. They will not become better at what they do. They are in it for exactly what they getting today.

They are in it for the money.

They are not in it for the patient nor their nursing profession

The saddest part was another nurse, my peer, and my equal; felt it was her right, her duty in fact, in front of everyone in the office to loudly say that the things that nurses write on their notes are "assumed" and perfectly acceptable. That she had seen my power point I gave to our supervisor and really it was what nurses learned in nursing 101 and the nurses did not need to be that specific on their nursing notes.

That what is written are assumed to be what we learn in nursing school is not only ludicrous but a lawsuit waiting to happen. That what you write is not all that you do and everyone needs to get over it is a blatant statement that nurses are above their own creed. That whatever we write is good and perfect and that anyone who differs to agree is a troublemaker is a perfect example of what I have been saying since 2006.

The nursing profession today does not want to be instructed, they do not want to learn, they want to get in and get out with as little effort and as little documentation as possible and god help the nurse who thinks she or he can change it!

The most important part of all of this comes from my David.

Any Nurse who feels they are superior, that their nursing skills and notes are perfect; are therefore stagnant.

And anyone who is stagnant will never learn.

Do NOT waste your time or your notes on them. Just document that you made the effort to assist them in perfecting their craft of nursing and move on to someone who is more worth your time and effort.

Thank you my David. I love you so much.


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Comments 8 comments

Happyboomernurse profile image

Happyboomernurse 5 years ago from South Carolina

Hi Barbara,

I felt ambivalent while reading this, but not because of what you've written, which is absolutely correct given the realities of the importance of good documentation. As you so rightly pointed out, an agency can not risk getting deficiencies for poor documentation and could even lose the right to medicare reimbursement if documentation is shoddy and does not reflect the care that was actually given.

My ambivalence comes from the fact that it is entirely possible to give EXCELLENT care and spend more time than average with your patients, and yet not have that reflected on the nursing notes.

And the opposite is also true. You could give substandard care, yet write notes that look like you gave great care. Of course, that's why medicare auditors make actual home visits instead of just reviewing the charts (and why nursing supervisors do the same thing).

In an ideal, non-litigeous world, tons of documentation wouldn't be needed. In an ideal world home care nurses wouldn't have to spend as much time documenting what they did, as it took to perform the actual job of nursing. In all my years of homecare, the only way I was able to keep up with my documentation and still spend quality unrushed time with my patients, was to do "documentation homework" every night and weekend (often unpaid because the main agency I worked for had a "policy" of no overtime).

Yes, your David is wise. You need to document (on an ongoing basis) that you've addressed the issue of substandard documentation with a particular nurse, and use the bulk of your time helping the ones who want to perfect their craft of nursing.

Also, even though you do not feel endangered by the verbal threat that the dramatic nurse made to you, it's important to make your own supervisor and/or the head of the agency aware of that nurse's unprofessional and unacceptable behavior.

God bless you for your big, caring heart and your desire to be the best supervisor you can be. Your nursing job is vital, but difficult and stressful. Spending quality time with your hubby is probably the best thing you can do to preserve your mental health.


RNMSN profile image

RNMSN 5 years ago from Tucson, Az Author

God bless you Gail

My boss told me to back off. that we have to take"baby steps"

that she doesnt need to "lose" a nurse, that he is "volatile" and when I wrote this I was not afraid/well now I am, cause she chose to call him last night and "smooth things over" by assuring him she would "take care of the situation and make sure I would not micromanage him"

and now I am told I must apologize to the entire staff for being a supervisor/even though I was doing only what and when I was told to do it by my boss...well Gail, you just wrote my "apology" that I am expected to give on tues at the care team conference...I am going to use your words verbatim....and I am going to let my boss know that I need this addressed...in all my yrs as a nurse, in the deepest part of the south, I have never been threatened to be killed

and today, even though I thought it would all have blown over... all I got from the young man...not young/he is 45/was a sneer and an "I told you so" look that chilled me.

I wasnt afraid before today/now I am

also come to find out he has actually cussed out a policeman and an emt during a home health visit!

my boss is married to a policeman and it was "taken care of"

so thank you happyboomernurse for writing the gist of my care conference/I also intend to sprinkle it with moving into the 21st century and the craft of nursing and the raising of the bar and that nothing we write is ever assumed

I want to die

I want to change the world

I want to make a difference

and all I can do is push the paper through

a hallmark shop sounds tempting...that or a lot of blood swirling in pretty red shades down the tub drain

it is you Gail and my hubby and the nurse at work that says I am awesome that keeps me away from sharp objects!

thank you

I love you

thank you

barbara b

one wonderful thing happened today..one of the nurses that took to my direction wonderfully and immediately sent me flowers at work today and the note said

"for pouring your heart and soul into everything you do"

I was also sent to do an admit today/the other clin sup was on call but said "I'm not doing it, you go do it"

so I did...even though I knew it was punishment,even though I realized I was being targeted/even though I knew they wanted to know if I could walk the walk or was I all talk/all the work done and turned in of course within 30 min of arriving back at the office and with raised eyebrows from my boss...geez thats what I have been saying from the time I was hired!!

That the nurses are NOT doing the notes in the home!! and yes you are correct, alot of time it takes homework but blank notes signed by the patient is fraud!!!!

/but most of the time you can get your notes done or at least partially done/ and your work done in the home during your visit! it takes perservience and organizaton but it is possible

anyway I am going to do a professional case conference with an outline and I am going to use your words so I hope you dont mind


Happyboomernurse profile image

Happyboomernurse 5 years ago from South Carolina

Of course you can use whatever words you feel are appropriate, but I have to say that after reading your above comment, I'm feeling inadequate to give you any advice. If it were happening to me, I would seek emotional support from a therapist and legal advice about what your rights are at work in terms of what steps your employer needs to be taking to ensure your safety and whether this situation should be reported to the board of nursing as unprofessional conduct. I don't understand the reaction of your boss, especially since the nurse has cussed out police and emt during a patient visit which shows that there's a pattern of volatility/intimidation by this nurse.

In terms of documentation being done while on a home care visit it sounds as though things have changed quite a bit from when I did homecare. Our patients had to sign a paper certifying we were there, but our documentation wasn't on the paper that they signed (except on the initial assessment which I did do in the home).

It is nice that one nurse that you've trained so thoughtfully expressed her appreciation of your dedication.


RNMSN profile image

RNMSN 5 years ago from Tucson, Az Author

well my David feels the same way/I also got out the rules of conduct from my hire packet and of course his behavior is unacceptable according to that paper not to mention harrassment and threats and unsafe work environment

all of which means nothing...what wll they do keep a field nurse that works every other wkend and makes 40-60 visit a week/albeit the work is poor and the documentation will eventually come out to show his work is non billable nonetheless I would be the one to be fired Im sure

as for the apology I will probably do a southern one with a smie and sarcasm and let it go

something like

I have been told by my superior to audit your work on paper and in the field and this is the second time my superior has told me to back off on you and to take "baby steps" with you in order to get your work up to par with the 21st century so I am sure I will be to told to repeat this to you again in the near future.

think anyone will "get" it?


LensMan999 profile image

LensMan999 5 years ago from Trans-Neptunian region

hello rnmsn you had well described the importance of documentation in this hub thanks for nice guidance.


RNMSN profile image

RNMSN 5 years ago from Tucson, Az Author

my pleasure lensman999!! thank you and love to you!!

barbara b


Home Health RN 5 years ago

As a home health nurse who has been in a supervisory role in a hospital setting I diagree with your negative outlook on nurses. Getting as many patient done in a small radius of time and miles is what I would call very efficient. Every patient and every visit is unique. The 10 minute med box for the poor eyesighted lady is just as important as the one hour wound vac dressing change that would not seal. I think the negativity is generated from nurses who have not walked the walk for a long time. Charting should be simple and direct. If I charted every word I said or every " please elevate your legs to reduce edema" I would NEVER be done.


RNMSN profile image

RNMSN 5 years ago from Tucson, Az Author

thank you for your insight home health RN...and remember that being attached to a hospital probably makes your documentation answerable not only to Medicare but JCAHO as well..."The thing that is constant about home health is the astronomical amount of paperwork that is required in order to pass muster for the government.

As it is, every home health agency worth its salt must be Medicare certified; regardless of how many HMO or different insurances they accept, they all must abide by Medicare rules and regulations.

This means that even though you (hope) know that nothing but Medicare charts will be audited by the government you must treat every patient as if they are just plain Medicare. The reason for this is clear.

Medicare has the most stringent rules and regulations about the care you deliver and the documentation you submit to support the justification of that care, The moment you let your staff become complacent about their documentation that is when you better be looking over your shoulder, because the auditor or the surveyor or the consultants will be on their way to your office"

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