What Every Visit Note Must Prove

Each visit must stand alone for the medical necessity of the service provided, and for the fact that the patient remains homebound. If there is no skill, or the patient is not homebound, you cannot complete and bill the visit.

That single sentence is the whole of this page. Everything below is how you put it into a note.

Why home health, and why now?

Answer it in the note, on every visit. Not just at the start of care.

What is your skill?

Name it. Assessment, education, or hands-on care.

• Assessment — Is there a new or exacerbated diagnosis? Narrate what you are watching for and why. "Assessed cardiopulmonary status" is not an assessment; "monitoring for fluid overload given 4 lb gain since Tuesday and new orthopnea" is.
• Education — Give the details of what you taught and why it is needed now: abnormal findings, noncompliance, a new or changed diagnosis. Include how the patient responded.
• Hands-on care — Detail the steps of the procedure and why it requires a nurse to perform. Could a caregiver be taught to do this? If not, say why not.

And ask the question behind all three: is there a caregiver? If a competent caregiver could safely do it, it is not skilled just because you did it.

Homebound status, every visit

You must prove the patient remains homebound on every visit billed, and the homebound reasons must match your assessment in the same note. A note documenting independent ambulation and a homebound reason of "requires assist to ambulate" is a contradiction a reviewer will find.

Ask:

• Why can this patient not receive this treatment as an outpatient?
• What prevents them from safely leaving the home?
• How much assistance is required to keep them safe when leaving?

It is not about what the patient is doing. It is about what they are safe to do.

Follow the plan of care

Review your plan of care for the interventions ordered. You can only complete interventions for which you have orders. Documenting an intervention you have no order for creates a problem rather than solving one.

If the patient needs something that is not ordered, get the order — see Verbal Orders and Clarifications.

Coordination of care

Who have you talked to about this patient? Document it, and take credit for the coordination you actually did:

• Conferenced with — name and discipline, and what was discussed
• Physician contacted regarding — who you spoke to and what time
• Order changes resulting

This is the section clinicians most often leave blank, and it is free credit for work already done.

Plans for the next visit

Why does this patient require another visit? Answer with one of:

• Continued assessment of an unstable condition
• Education still to be delivered
• Reinforcement of education not yet retained
• Hands-on care that still requires a nurse

"Continue plan of care" is not an answer. Write what you will actually do, specifically enough that the next clinician could pick it up: "re-educate on insulin, patient to return demonstrate."

Discharge planning starts at the start of care

Discharge planning begins at SOC, not in the last week. Every note should move toward it:

• What is the goal?
• How are you preparing the patient for discharge and self-care?
• What has to be true before this patient no longer needs us?

For example: "must be able to self-inject insulin." That is a discharge criterion anyone can measure.

Fill in every box

Assessments are point-click plus narrative, and every box gets filled in.

Chart towards the patient's goals — and address these on every assessment whether or not a goal exists for them:

• Wounds
• Pressure
• Pain
• Hospitalizations
• Discharge planning
• Fall risks

If any of those are missing from the patient's goals, notify the RN Case Manager and ask for them to be added. The same applies to a goal you think the patient should have, or would benefit from.

Once a specific goal is met, you may chart the intervention as completed or performed.

Signing the visit

The house-shaped box beside the patient's assessment is how the patient signs for the visit, if able: click the maroon box, have them sign, Save, then Continue — the house turns green, meaning the visit is signed for. This box is not currently in regular use.

The orange house beside it records a missed visit — see Missed Visits and Non-Admits.

Items that are required every visit when present

• Vital signs and pulse oximetry — every visit, every skilled discipline. See Vital Sign Parameters.
• Stoma appearance — required at every visit if an ostomy is present
• Homebound status — every visit, matched to your assessment
• Skilled intervention — tied to an order on the plan of care

The reviewer's version of your note

When a reviewer reads a visit note, they are asking four questions in order:

1. Was there a skilled service, and does the note show why it required a clinician?
2. Was the patient homebound, and does the assessment in this note support it?
3. Was the intervention ordered on the plan of care?
4. Does this note justify another visit?

If your note answers all four before they have to look for it, you will rarely hear from them again.