7 Section
Documentation
Charting standards, skilled language, and what reviewers look for.
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7.1What Every Visit Note Must Prove
Each visit has to stand on its own for skilled need and homebound status. Here is what that means field by field.
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7.2Vital Sign Parameters — When to Call
The agency's notification parameters, when to call the PCP, and why a value that normalises before you leave still gets reported.
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7.3Skilled Language — Writing What You Actually Did
The verbs that carry skill, the phrases that quietly say "unskilled", and side-by-side rewrites of the notes people actually write.
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7.4What Reviewers Look For
Who reviews home health charts, the inconsistencies they find first, and how to read your own chart the way they will.
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7.5Corrections, Addenda, and Late Entries
How to fix a mistake in the record properly, what never to do, and why the way you correct something matters more than the error itself.
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7.6Incidents and Occurrence Reporting
What has to be reported, the separation between the incident report and the medical record, and why reporting a near miss is the most useful thing you can do.