Turtle62

Hi Nurse Candy. It sounds as though home health may be new to you. Home Health documentation is a little different than documentation in other settings. While you still must include your patient's assessment, any procedures that you perform, your instructions to the patient, and their responses to all the above, you also have to remember how to document for reimbursement. If you are new to homecare, it is a lot like learning a new language. My best advice is to review your notes with the performance improvement guru in your agency, she/he will know what wording to use to make your notes the best they can be. If your agency does not have one person assigned to performance improvement check with your immediate supervisor and ask for a mentor until you feel comfortable. Good luck-Turtle62