Defensible Documentation: Five Essentials for Home Health Providers

Getting documentation right the first time saves time and can increase the quality of patient care. Does your agency's documentation strategy include these five essentials?

As payment models shift from volume to value, health care providers must meticulously document every step of their care plan and track results to prove they're providing consistent, high-quality care. Poor documentation carries severe financial penalties including delayed or denied payments and fewer referrals from hospitals and physicians. Create a defensible documentation system that can withstand the scrutiny of auditors, watchdogs, and other health care providers.

Essential #1 - Take Documentation Seriously

You agency may never have been audited, but be prepared for extra scrutiny. In July, Federal oversight investigators told Congress that CMS made more than $16 billion in improper payments to private Medicare Advantage providers in 2016. Officials also cited home health agencies for documentation errors, without specifically citing fraud as a reason for the problems:

CMS official Jonathan Morse did little to clear up any confusion over billing mistakes. In his written testimony, he said that improper payments are “most often payments for which there is no or insufficient supporting documentation to determine whether the service … was medically necessary.” 


With billions at stake, the Office of the Inspector General's 2017 Workplan promised more scrutiny for caregivers and insurers. The National Law Review warned, "Healthcare organizations are well-advised to review their internal audit and compliance plans on a regular basis" and encouraged providers to use the workplan as a guideline. One area of focus was "assessment of home health agency accurate reporting of patient information for recertification survey."

Assemble a dedicated compliance team to perform random internal audits. That will help you identify and correct problems before regulators find them.

Essential #2 - Train Staff on Workflow Documentation & Management

Most documentation errors are mistakes - but costly ones if they result in denial. Staffers must know who is responsible for what and understand how to document care. Every new initiative like value-based purchasing and alternative payment models, brings new requirements.

Even long-time employees need regular training on new systems, billing codes, and basic instruction on completing new documents. The time and money spent on staff education and training is an investment in your success.

Essential #3 - Communicate With Stakeholders

The 2016 Pre-Claim Review (PCR) rollout in Illinois was rocky at best, partially because physicians weren't adequately trained and informed about their roles in the process. A recent study by researchers at the University of Colorado School of Medicine highlighted communication problems between physicians, hospitals, and home health providers as a contributing factor to hospital readmissions.

"Many areas of care are disrupted by communication challenges, including disparities in medication lists, lack of clarity in who is responsible for writing patient care orders, inaccessible hospital records and resistance from clinicians to accept accountability."

Better communication improves the patient's quality of care, outcome, and satisfaction - all of which affect an agency's CMS STAR rating. In some cases, agencies worked to help physicians and hospital personnel understand new CMS requirements and regulations. That kind of collaboration helps build positive relationships and improve documentation quality.

Essential #4: Maintain Complete Documentation - For Patients & Payers

Remember that the quality documentation you provide as part of patient care may not be enough to satisfy payer requirements. They expect you to prove that any care provided was "reasonable and medically necessary." If you can't, the claim is denied.

Basically, the more information you provide about the patient's condition and progress, the better.  It's not enough to mention in a treatment note that patient "can walk unassisted for short periods," for example. Instead, include objective measurements like "patient was able to walk unassisted from the bedroom to kitchen, a distance of approximately 20 feet."  Each subsequent treatment note should track that progress as well.  The documentation taken as a whole should offer a complete narrative of the patient's initial condition, progress, and outcome.

Consider the audience when telling this story. Trained health care professionals recognize jargon and acronyms. Government contractors or insurance company employees without medical training may not. Reports and notes should contain explanations that laypeople can follow and understand.

Essential #5: Improve Documentation and Communication by Leveraging Technology

Technology is a critical factor in defensible documentation. It places a patient's medication record and treatment plan literally at your fingertips. Everyone works off the same plan and has the same information. This helps prevent avoidable problems like adverse drug interactions, conflicting provider instructions or denials due to incomplete documentation. But only if you use it!

New initiatives like value based purchasing require communication and collaboration between caregivers.  As the American Hospital Association reported:

The current inability for electronic systems to speak the same language to one another and to efficiently and correctly transmit information – to be interoperable – is among the most pressing issues facing health care stakeholders today.


Even so, many small to medium-sized providers are reluctant to change systems. While they recognize the benefits, they worry about the system's purchase and training costs.  Homecare Homebase offers cost-effective solutions that help you move from clipboards to tablets, from spreadsheets to robust tracking. We help you increase data reliability and meet the demands of new quality and payment models. HCHB also offers interoperability tools that connects users and referrers, including connection to large, hospital-based EMRs.

Defensible documentation is a straightforward concept. Problems arise from insufficient training, confusing regulations, and communication problems with other stakeholders. Be proactive to stop problems before they start.