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.
