Documentation and effective patient care planning. 1996

T M Marrelli, and L S Hilliard
Marrelli and Associates, Inc., Health Care Consultants and Publishers, Westerville, Ohio, USA.

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.

UI MeSH Term Description Entries
D009737 Nursing Records Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress. Records, Nursing,Nursing Record,Record, Nursing
D010347 Patient Care Planning Usually a written medical and nursing care program designed for a particular patient. Nursing Care Plans,Goals of Care,Plans, Nursing Care,Care Goal,Care Goals,Care Plan, Nursing,Care Planning, Patient,Care Plans, Nursing,Nursing Care Plan,Plan, Nursing Care,Planning, Patient Care
D012051 Reimbursement Mechanisms Processes or methods of reimbursement for services rendered or equipment. Mechanism, Reimbursement,Mechanisms, Reimbursement,Reimbursement Mechanism
D003152 Community Health Nursing General and comprehensive nursing practice directed to individuals, families, or groups as it relates to and contributes to the health of a population or community. This is not an official program of a Public Health Department. Nursing, Community Health
D006278 Medicare Federal program, created by Public Law 89-97, Title XVIII-Health Insurance for the Aged, a 1965 amendment to the Social Security Act, that provides health insurance benefits to persons over the age of 65 and others eligible for Social Security benefits. It consists of two separate but coordinated programs: hospital insurance (MEDICARE PART A) and supplementary medical insurance (MEDICARE PART B). (Hospital Administration Terminology, AHA, 2d ed and A Discursive Dictionary of Health Care, US House of Representatives, 1976) Health Insurance for Aged and Disabled, Title 18,Insurance, Health, for Aged and Disabled,Health Insurance for Aged, Disabled, Title 18,Health Insurance for Aged, Title 18
D006699 Home Care Services Community health and NURSING SERVICES providing coordinated multiple services to the patient at the patient's homes. These home-care services are provided by a visiting nurse, home health agencies, HOSPITALS, or organized community groups using professional staff for care delivery. It differs from HOME NURSING which is provided by non-professionals. Domiciliary Care,Home Health Care,Care Services, Home,Home Care,Services, Home Care,Care, Domiciliary,Care, Home,Home Care Service,Service, Home Care
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D014481 United States A country in NORTH AMERICA between CANADA and MEXICO.
D017063 Outcome Assessment, Health Care Research aimed at assessing the quality and effectiveness of health care as measured by the attainment of a specified end result or outcome. Measures include parameters such as improved health, lowered morbidity or mortality, and improvement of abnormal states (such as elevated blood pressure). Assessment, Outcome,Outcome Assessment,Outcome Assessment (Health Care),Outcomes Research,Assessment, Outcomes,Outcome Measures,Outcome Studies,Outcomes Assessment,Assessment, Outcome (Health Care),Assessments, Outcome,Assessments, Outcome (Health Care),Assessments, Outcomes,Measure, Outcome,Measures, Outcome,Outcome Assessments,Outcome Assessments (Health Care),Outcome Measure,Outcome Study,Outcomes Assessments,Research, Outcomes,Studies, Outcome,Study, Outcome

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