Skip to content

Enhancing Home Health Therapy Documentation Practices

    Conducting the Initial Therapy Evaluation

    There are two objectives to fulfill when conducting the initial therapy evaluation: 1) emphasize that skilled therapy services are medically necessary, and 2) identify the specific areas to focus on during succeeding patient visits.

    Obtaining approval from the certifying physician or provider before continuing with therapy is always necessary. During the first encounter, the therapist sets expectations for the overall treatment plan and future visits. By carefully reviewing the patient’s medical history, the therapist can pinpoint major issues and ask relevant questions during the evaluation. Assessing the patient’s previous level of function is vital in establishing goals and justifying the need for skilled services.

    Thorough therapy evaluations involve interviews, observations, and hands-on assessments to create an accurate baseline assessment. They cover important aspects such as functional skills, safety, home environment, accessibility, mobility, and factors that may impact treatment.

    Setting Attainable Goals in the Plan of Care

    Treatment goals established in the Plan of Care by therapists must be realistic, measurable, and patient-specific so as to directly address the patient’s injury and resulting functional impairments.

    Involving the patient and caregiver in developing the treatment plan is crucial in ensuring the patient’s commitment to and active cooperation with the treatment. The treatment plan should also indicate the expected duration of therapy services and describe the treatment process, aligning with the qualified therapist’s assessment of the patient’s functional ability and the established goals.

    Demonstrating Medical Necessity in Documentation

    The therapist’s documentation should support and demonstrate the medical necessity of the skilled service provided. It should include details of patient education and training activities, showcasing specific skilled instructions, teaching, and training conducted by the therapist.

    Using objective measurements, the documentation should also indicate the following:

    • patient’s response to treatment
    • their progress toward therapy goals
    • ongoing impairments that require continued skilled care
    • patient and/or caregiver’s ability to understand and recall the taught information

    Each daily visit should include a specific and detailed plan for the next visit. Avoid using generalized and vague descriptions, as they may increase the risk of claim denials. The documentation should clearly convey the patient’s status, adherence to the ordered plan of care, and measurable progress toward goals, providing a comprehensive picture of the patient’s care trajectory.

    Thoroughly document all communications involving the patient, caregiver, team members, and physicians/providers, including reported changes, abnormal findings, and actions taken.

    Effective Communication and Collaboration with the Patient

    Effective communication and collaboration with patients, caregivers, team members, and providers are vital in enhancing the quality of care, ensuring accurate data, maintaining compliance, and building a comprehensive and reliable medical record.

    They also play a critical role in exceeding outcome averages and helping consumers select a home health provider through public reporting programs like Care Compare and Home Health Value-Based Purchasing.

    The Importance of Timely Documentation

    Completing documentation in a timely manner is crucial. Delayed charting increases the risk of missing out on important details and can impact patient safety and timely treatment delivery. Insufficient, unsupported, or inaccurate information from late documentation can also lead to reimbursement adjustments, delays, or denials. Finally, timely documentation minimizes the possibility of payment setbacks and justifies services for proper payment.

    Getting Integral Support for Quality Documentation

    Timely and accurate documentation is essential in therapy and all home health services. However, achieving this can be challenging due to complex guidelines and the fast-phased nature of clinicians’ work in home health. Additional support is necessary to ensure the timeliness and accuracy of documentation.

    A robust QA and coding program would provide invaluable assistance to clinicians by helping ensure their documentation is complete, accurate, timely, and consistent with other relevant patient records. Work with knowledgeable QA reviewers and coders who can not only identify and improve documentation areas but also contribute to re-education efforts, helping clinicians enhance their skills and make high-quality documentation sustainable.