Documentation Basics for Home Health

Before starting my article I will like to say a few words about health.

“Every human being is the author of his own health or disease.”
“He, who has health, has hope. And he, who has hope, has everything.”
“It is health that is real wealth and not pieces of gold and silver.”

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 OASIS

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…

Source by Noman Khan

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