Over the last 10 years I have spent a lot of time personally auditing records and collaborating with those who perform that task in homehealth agencies. No matter the size or location of the agency, there is a clear, common theme – the ongoing struggle to get clinicians to document skilled care.

Educational efforts take the form of in person sessions,webinars, books, articles and audio conferences yet the issues seen in content generated by nurses and therapists remain virtually unchanged.

• 1) Incomplete assessments
  • a.Limited to no subjective input from the patient and caregiver
  • b.Objective information recorded but no clinical analysis
  • c.OASIS information inconsistent with narrative findings

• 2) Goals that are long on number and short on focus
  • a.Goals that are actually tasks for the clinician
  • b.Lack of connectivity between the assessment, plan and goals
  • c.Measurement present but no clear meaningfulness to the patient

• 3) Visits not showing “skilled need”
  • a.Repetitive visit note content
  • b.Inconsistencies between disciplines
  • c.Unclear relationship between visit notes and the plan of care

Let’s be honest – clinicians HATE to document . There is no quick fix for years of learned behavior from clinicians that repeatedly asks others “just tell me what you want me to write”. The time has come to address the core issue – do we understand “skill”.  Blog Continued Here
 

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