Home Care Clinical Documentation: Solve Common Challenges in Your Agency

Home care agencies rely on clinical documentation for fast reimbursement as well as better quality of care. However, many agencies can struggle with documentation compliance for a variety of reasons. Here are some common pitfalls that even the most veteran home care staff can fall into, as well as how to use technology advancements to find a solution that works for your team.

Documentation Challenge #1: Shuffling Paperwork

Home care caregivers and nurses don’t have a centralized office or more traditional nursing station, where they can grab a chart and complete paperwork before the end of a shift. Instead, home care employees, especially nurses, are seeing patients in the patient’s home. Most home care nurses are visiting 3-5 patients per day, performing assessments or follow-ups, as well as providing treatment. 

It’s no wonder most nurses end up using their vehicles as a makeshift office, throwing patient files in the backseat or jotting down vital signs on a scrap piece of paper from their bag. Unfortunately, this disorganization can quickly lead to privacy violations and missing information.

Technology as a Solution

Even if your agency has eliminated paper charts and documentation, and switched to electronic medical records to streamline the process, you still may not be utilizing technology as best as you can. Look for a technology solution that offers nurses an easy to use app for their smartphones that puts all of their patient charting on a centralized dashboard that is easy to navigate.

Documentation Challenge #2: Missing Reports

Everyone who has worked in healthcare for even just a few months knows the old saying that states “if you didn’t document it, it didn’t happen.” Unfortunately, missing documentation can do more than just delay reimbursement or increase staff miscommunication. Missing or incomplete documentation can also lead to increased hospitalizations due to missed signs of illness or incorrect care interventions.

Technology as a Solution

Nursing notes and documentation are complex. To be most effective, nurses must be able to not only complete their documentation, but also alter the patient care plan as needed and communicate any changes quickly to caregivers. Search for a solution that makes documentation and communication easy through an app that offers notifications for missing reports as well as offers the option to immediately alter the patient care plan. The easier it is to use, the better your team’s compliance will be with documentation tasks.

Documentation Challenge #3: Follow-Ups and Reassessments

Home care nurses are busy! Between their patient visits, they are completing documentation and sometimes managing a team of caregivers. It’s easy to see how a follow-up or reassessment can slip through the cracks even if it is written on their calendar or to-do list. Unfortunately, missing a follow-up or reassessment within a specific and required time frame can lead to slower reimbursement rates and poor patient care.

Technology as a Solution

The right platform can eliminate missed follow-ups while making life a bit easier for all of your busy clinical staff. Find a platform that automatically generates schedules for reassessments and follow up visits. This will ensure a follow-up appointment is never accidentally missed and documentation is already in the dashboard, waiting for the nurse to complete it.

Documentation Challenge #4: Slow Communication Time

If a caregiver documents that a patient has a new cough or is acting more confused than normal, it can take too long for that information to reach the patient’s nurse in most cases. While home care agencies across the country are working diligently to empower caregivers and remind them that their documentation truly helps set the bar for exceptional care, if there is not a way to quickly push that information to the nurse for follow-up, the patients suffer and the caregivers feel frustrated.

Technology as a Solution

Even if your electronic medical records system currently gives caregivers and nurses the opportunity to document changes in condition on a laptop, tablet, or smartphone, if your system is not set up to push those changes to the right people, you are still missing out on the chance to follow up with a patient. Search for a solution that allows online documentation and then alerts nurses when a patient falls below a certain threshold or baseline. This ensures the nursing team receives the information quickly and has the opportunity to follow up immediately, decreasing the risk of an unnecessary hospitalization or crisis.

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"Most home care agencies struggle with documentation compliance at some point."

Documentation Challenge #5: Privacy and HIPAA Compliance

It’s difficult to ensure privacy when nurses and caregivers are documenting in patient homes, in their cars, and even on the subway ride to their next destination. The situation only becomes more complicated when physicians, pharmacies, and other medical professionals need to get orders or documentation to your home care nurses. Do you fax it? Email it? Can you be sure the information is confidential as it passes through a variety of systems and sets of hands?

Technology as a Solution

Ideally, your nurses should be able to receive orders and information from physicians on their smartphones or tablets thanks to an easy-to-use app and platform. Search for a technology solution that allows that information to be effectively and efficiently available with the tap of a button. This will streamline the process and improve communication between the patient’s medical team.

Here’s the bad news: most home care agencies struggle with documentation compliance at some point. The good news is that you can address common challenges, improve patient care, and make your clinical team’s jobs even more efficient by finding the right solution for clinical documentation.

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