The Evolution of Documentation in Home Health

Abstract

There is evidence of an evolution in documentation in home health that has its roots in government agencies and mandates. Agencies from Medicare and Medicaid to the Health Insurance Portability and Accountability Act supervised by the Department of Health and Human Services have made clinicians accountable for the care they give and the personal health information they collect. The need for in-home care, the care provided, and the outcomes of the care given are evidenced by documentation. The documentation allows for reimbursement. Patient care and the time needed to complete and document that care have become complicated and timely. Has this affected patient care? Clinicians vary in their opinions. However, all agree that the criteria and methods of documentation have evolved from the simple to the complex.