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New Year, New SOP: How to Improve Your Team’s Documentation


We already know reviewing billing processes for accuracy and efficiency is the first step toward growing revenue, but taking this first step does not mean that achieving financial success is guaranteed. This is just preparation for the journey, gassing up the car and checking for a spare tire before the long trip.

A frequent pothole you need to avoid in the claims-processing road to reimbursement is caused by documentation processes, or a lack thereof. Standard operating procedures (SOP) that are clearly defined for documentation will speed up your trip and ensure no reimbursement opportunities are passed.

Tips to Help Create Standard Documentation Processes

Use these tips to create documentation SOPs for your home health organization.

  • Get as much information as possible from your referral source, and if required, try to get the face-to-face up front. This will provide you with a good medical history and some background regarding the patient’s needs (skilled or unskilled).
  • When speaking with the patient or family before admission, ensure you get as much information as possible regarding contacts, additional care needs and any scheduling limitations, such as adult day care, etc.
  • The initial assessment should be as thorough as possible, with all questions already answered. If required to do an Outcome and Assessment Information Set (OASIS), provide additional education on completing it correctly; incorrect or inadequate responses can decrease potential reimbursement. Prioritize consistency of information, from the comprehensive assessment to the OASIS and the Plan of Care (POC).

Physician orders must be obtained for delays in care or unusual circumstances. Do not forget to change the referral date to reflect when the last of the patient information was received or the date of discharge, as this comes up in the OASIS and may be important for documenting continuity of care.

  • Ensure a consistent interpretation of questions. It helps to talk about it as a team once all disciplines have made their initial visits.
  • Encourage your team to analyze and interpret changes and make adjust to the POC as soon as needed. These changes must be documented.
  • Complete the documentation timely, at the time of visit whenever possible. Even a small delay can impact a clinician’s memory of events.
  • All documentation must be reviewed for accuracy, home bound status and medical necessity.
  • Therapy and nursing goals should be specific and measurable. Include measurements when possible to illustrate progress towards goals.

A major component to adopting new procedures is keeping staffing consistent. Inconsistent staffing can result in documentation responses that do not demonstrate patient progress towards goals, as different clinicians generally bring their own bias and understanding of the goals.

Quality control in documentation is a must, so be sure to review those elements. With your entire organization operating in the same vehicle, the road to reimbursement will be smooth and easy to navigate.

Axxess Home Health, a cloud-based home health software, includes mobile OASIS documentation driven by compliance for the highest reimbursement.

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