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Knowledge Point Articles   

February 2006

Simplification of the Documentation Process for Home Health and Hospice

We all know the importance of documentation in the process of quantifying the patient care progress. The old adage, “If it wasn’t documented, it wasn’t done” holds true in any setting. But the better questions may be: "What should we be documenting" and/or "what should we not be documenting"?

A well-known complaint from health care providers is the perception of the overwhelming percentage of paperwork time required compared to the actual time spent in the provision of patient care. And the ever-increasing regulations put significant emphasis on the documented paperwork to prove positive outcomes have been achieved.

The end result of all this documentation is to be able to receive the proper reimbursement that will allow us to stay financially stable so we can continue our stated missions of providing high quality, affordable and accessible health care for those in need.

The dilemma is how do we simplify the process to meet both the regulatory requirements and still improve the ratio of actual time spent in direct patient care versus the time spent with paperwork and documentation?

Things to consider are: 1) we do not need to be creative writers. If that were needed we would be recruiting liberal arts and English majors instead of Registered Nurses and other health care providers. We need to remain focused on the facts and only the facts; 2) consistency in the assessment process and the subsequent documentation is the cornerstone to being able to determine the effectiveness of the whole health care delivery process and the subsequent positive outcomes, or lack thereof; 3) we all need to be “speaking” the same language and incorporate the use of standardized or acceptable abbreviations; 4) we never want to be redundant in what we document; 5) do not be afraid of “standardized” language. The more “standardized” the better, as long as you edit it to address individual patient needs; 6) standardization of the assessment and documentation process can allow the energy of the practitioner to be focused toward utilizing their clinical skills and expertise for patient care rather than spending valuable time in this necessary documentation process; and 7) consistently using “standardized” assessment and documentation procedures can provide a baseline standard to measure against. If you do not have a consistent approach for all clinicians to follow, you create a situation that has too many variables to achieve accurate measurement of outcomes.

What do we need to do to achieve the goal of completing documentation that has successfully described patient outcomes (or lack of), decrease the time clinicians utilize in the process of documentation and still meet all regulatory requirements that ensure reimbursement for the care provided?

Ultimately, we need to have clinical pathways that are user-friendly and professionally developed to assure best practice standards. We also need the appropriate policies & procedures that enhance the successful incorporation of the pathways into a Home Health or Hospice organization. Utilizing clinical pathways will assist in assuring standardized, concise documentation that focuses on the patient outcomes and demonstrates the quality patient care delivered by the clinician.

Cynthia Nyquist, RN, BSN, MSN
Executive Director/CEO, Upper Pennisula Home Health and Hospice

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