Home Health Articles and Information


Apr 2, 2019 12:13:00 PM / by Michael McGowan, CEO, OperaCare LLC.

Charting for Home Health Success

If you are responding to a bottomless pile of ADR requests, entering another round of Targeted Probe and Educate, or maybe even a ZPIC/UPIC pre-payment review, I suggest you take a step back and ask yourself the following:

How are my clinicians doing their charting? Are they relying on check boxes, or is the record my agency is about to submit for review filed with robust, data-rich longitudinal charting that describes the patient’s unique individual story in direct correlation to the severity of the illness or injury being treated?

If it’s the former, then I need to tell you about CMS not so well-kept secret:


CMS expects longitudinal charting.


The Medicare Benefits Policy Manual (MBPM) has this to say about home health charting:

“Clinical notes should be written such that they adequately describe the reaction of a patient to his/her skilled care. Clinical notes should also provide a clear picture of the treatment, as well as “next steps” to be taken. (Longitudinal Charting) Vague or subjective descriptions of the patient’s care should not be used. For example, terminology such as the following would not adequately describe the need for skilled care:


Patient tolerated treatment well

Caregiver instructed in medication management

Continue with POC”


Clinical notes are expected to tell the story of the patient’s achievement towards his/her goals as outlined in the Plan of Care. In this way, the notes will serve to demonstrate why a skilled service is needed.

The MBPM continues…by instructing us to document as illustrated below

Following these points in the order presented creates a longitudinal chart with each note building toward proving medical necessity and reaching outcomes and goals, protecting you from audit activity and ensuring success.


Tags: PDGM, Home Health, Quality assurance, OASIS

Michael McGowan, CEO, OperaCare LLC.

Written by Michael McGowan, CEO, OperaCare LLC.

Michael McGowan is a former State/CMS Region IX OASIS coordinator and president of OPERACARE. Based in Socorro NM. The company utilizes proactive OASIS analytics to exploit the entirety of PPS system, establish financial predictability, minimize ADR’s & Audit risks, and monitor OASIS outcomes. The company’s remote monitoring services mimic Intermediaries and audit contractor’s activities to quantify your risks and validate the care you deliver.