Documentation and effective patient care planning

The creation of effective home care documentation serves many important purposes. From a payor perspective, such as Medicare, the clinical documentation can provide the basis for covered care. On the other hand, poor documentation can raise questions about medical necessity and even eligibility criteria, such as the patient's homebound status. Documentation can either support payment for covered services or begin the cycle toward increased requests for information and more-focused medical review processes. The following discussion provides key tips, information, a comprehensive checklist, and outcomes examples that support the creation of "best practices" for home care organizations related to clinical documentation.