Home Health & Hospice

Focus on Documentation of Skilled Procedures

Homecare Insider, June 20, 2011

Documentation in the clinical record must reflect that procedures require the skills of a nurse. Agencies should begin with documenting pertinent history and assessment findings. Documentation should include a description of the patient’s limitations. The plan of care should identify a diagnosis to correlate with the procedure and reflect complete details of the procedure.

Documentation on visit notes should include details of the procedure performed. It raises questions when clinicians document broadly by stating something similar to “procedure done per the plan of care” or “procedure done per physician order”. It’s always best to be as detailed as possible, even though it takes a little more time. If not, surveyors may question whether or not the clinician actually did perform the procedure as ordered in the plan of care.

Documentation of skilled procedures should also include the patient’s response, including how the patient tolerated the procedure and any change in the patient’s status. Clinicians must also remember to report to the physician and document any significant findings and changes in the plan of care.

Looking for more information on clinical documentation? Beacon Health’s audio conference “Clinical Documentation Compliance” is available on CD for staff education. This audio conference explains how to avoid missed payment in areas such as observation and assessment, management and evaluation, and maintenance therapy due to incomplete documentation. This audio also discusses documentation of the face-to-face physician encounter.