Medicare Charting Guidelines for HH

[roach930]

I have been working in home health for about a year and a half now. I'm sure I have the same loves and the same frustrations of almost every other home health nurse. I have been searching topics on this site for a while now and still cannot find the answer to my question, so I figured I should just post it. My boss continually shortens the amount of time that all charting is "due" and blames it on Medicare Guidelines changing. No matter if we see 10 a week or 40 a week, he/she expects everything done on the same timeline. I have spoken with a colleague in a different agency who says no changes have been made and the only guideline out there is for 30 days. What I would really like is to know exactly where I can find guidelines pertaining to charting and when it is "due" so I can see if I'm justified in my frustration or not. I would ask my boss, but I suspect my question would not be met with much delight in answering it. I find it funny that an occupation, so focused on paperwork, makes it very hard to find guidelines on completing said paperwork. Thanks for any help.

[KittyLovinRN]

Our charting (all computerized) is to be locked down and transmitted by midnight after the visit was performed. Granted there are times where we slack and do it the next day but it is the expectation that it's done by midnight.

[I<3H2O, BSN, RN]

We want all our of charting to be done and completed "same day" with the exception of SOC OASIS. I wouldn't want to sit on open charts for days on end.

[toomuchbaloney]

You need to incorporate your documentation into your visit time, it is an IMPORTANT part of the visit in fact. Without the documentation there is no evidence that you actually completed the visit, so it is imperative that you begin to see point of service documentation as your friend.

The ideal expectation should be that you visit the patient, complete your skilled assessment and care, and then document your visit before leaving the home.

[ttouslee]

I agree with the others here, documentation should be completed by end of day. I tell my staff if they do not want to chart at the visit, they have to have it written on paper (we do computer charting) no way you can remember specifics after a long day of visists; and imagine the state doing a ride along and you don't write anything down at the visit.

As for a SOC, needs to be completed in 5 days, but some agencies want it to the CM sooner