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There are many kinds of documentation methods and systems in home care and hospice at home. Some are primarily a blend of paper and data entered on a device, such as a tablet. Many organizations have chosen one vendor only to later find a better one—and sometimes it is the clinical documentation system that makes the biggest difference for success. It is intuitive that documentation of the nursing and/or the care planning process be integrated in the system’s processes.

The information in this chapter is about documentation, in whatever format your organization uses. Documentation needs to meet a number of objectives to be effective and show value. Documentation describes clinician practice to state or accreditation surveyors, peers, payers, managers, patients, families, and others who may review patient records. Keep in mind that this may also include lawyers and juries. Be aware, too, that there is now more access for patients and families to review and keep their clinical records—which makes sense from a self-management perspective. This is not said to cause you worry, but you should be aware that many people, with permission of course, have access to and read clinical records. This is another reason to clearly and objectively document.

Value and getting paid or reimbursed “for value” begins and ends with clinical documentation. The question to ask, then, when reviewing documentation—such as a comprehensive assessment, a visit note, or care coordination and/or communication notes to other team members and/or a discharge summary—is this: “Is the value of the care reflected in clear, understandable documentation that paints a picture of that patient’s status, healthcare problems, case management, care coordination, care, and interventions directed toward improvement and/or comfort toward the end of life?”

This is how clinical documentation needs to be viewed, through the lens of value and quality. Documentation impacts many areas of practice and care in the healthcare environment generally, and perhaps even more so in the home care and hospice at home environments.


Now that the patient exemplar (from Chapter 7, “The Home Visit: The Important Unit of Care”), Mr. Hinckley, is back at home, one of the main goals of the home care organization and team is to keep him out of the hospital, thus working to prevent a rehospitalization. How this is best accomplished will continue to be studied, but we do know what works best for some patients. The body of literature and science is growing on this important aspect of care. And efforts toward this goal should be documented.

According to the U.S. Department of Health & Human Services, “the all-cause 30-day hospital readmission rate among Medicare fee-for-service beneficiaries held constant from 2007 to 2011, generally between 19-19.5 percent of beneficiaries readmitted to the hospital within 30 days. This rate fell to 18.5 percent in ...

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