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.
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.