There’s nothing finer than having your paperwork done at the end of the day
Should it be done in the home or the driveway?
Take any work-related task, and you’ll find that home care agency staff have as many different ways to perform it as there are people to handle it. Different approaches can lead to new and, at times, improved ways of handling a requirement. But there are instances when using a different approach results in lost time and productivity, and in the case of home care assessments, it might even lead to incorrect data. One example is documentation. Some home care nurses and aides prefer to — or are required to — perform it on-site, while others prefer to save it all up for one lengthy paperwork session.
Which way is the right way? Some home care professionals say that there is already so much paperwork to be done in the home that any documentation that can be done outside the home should be. Otherwise, it takes too much time away from the patient visit.
"For 25 years, I have been trying to convince staff to complete charting in the home," says Diann Martin, RN, DNSc, with LM Cantone and Associates in Wilmette, IL. "Most don’t like to. However, the ones who get into the habit certainly find it helpful. I try training them on this system from the beginning as new orientees. I can understand why an admit [document] may not be possible, but progress notes are a different animal, and I think it is a real timesaver and an efficiency issue. Sure, some homes are too chaotic with kids bouncing off the walls, but many aren’t."
Vicky Tataryn, quality improvement consultant with Continuous Care Services in Nashville, TN, agrees that finishing documentation in the home can be a challenge, up to a point. "Yes, it is hard to do the paperwork when you are up to your eyeballs in a really gooey dressing change," she says. "However, I also have observed that what takes me 10 minutes to do sitting in a parking lot in my car takes 30 when I try to do it at home or at the office.
"Therefore, my suggestion always has been to complete the paperwork from one visit prior to going to the next visit," Tataryn continues. "Pull over in a parking lot, sit in the patient’s driveway a few minutes, and if you have another patient that you’re running late for, that sense of urgency will be there to speed you along. It is heaven to pull into your driveway at the end of the day with your paperwork complete. That’s what I tell new home health nurses, and the ones [who] do it are happier campers at the end of six months then the ones who [don’t]."
Although she no longer works for a home care agency, when she did, Meri Shaffer, RN, now a program manager with Homeadvantage in Fairfax, VA, was a project manager and oversaw the implementation of 150 laptops in the field between two home health agencies. Her agency shared the system with another hospital-based home health agency 70 miles away.
She says that whether paperwork was completed in the home was dependent on the clinician — and not always to the staff member’s advantage. To make it easier on the staff, Shaffer says, "we came up with a semichecklist, where part of it was fill-in-the-blank and some was narrative. We tried to cut down the paperwork as much as possible, and most people did complete it in the home. Still, there were others who would take time to write down all their notes on a steno pad and then take time to transfer the notes onto the form when they got home. We had someone save up her notes for a week before she would transcribe them, and it took her hours. When we went to laptops, she transferred the same work habit, and it took even more time."
For her part, Shaffer finished her paperwork on-site or as soon after the visit as possible. "My feeling was such that I wrote most of the notes in the home unless there was something I didn’t want a patient to see. I had one patient who saw that I had written SOB [shortness of breath] on his chart, and he took it completely wrong. Whether it’s paper or electronic documentation, when I would make visits, I always tried to get all of it done and advised my staff to do the same. Not only did I not have the burden when I got home, but information was fresh in my mind and certainly more accurate," she says.
Getting it right
Accuracy is one of the best reasons for completing the paperwork as soon as possible after, if not during, the visit. "For data accuracy, thoroughness, and to provide clinicians, agencies, and HCFA [the Health Care Financing Administration] with more accurate visit times, seems like in-home documentation is necessary," says Linda Krulish, PT, MHS, president of Home Therapy Services in Parker, CO.
But there’s more than accuracy at stake when it comes to completing documentation in the home. "The in-home visit time that we report to HCFA is the data that it will use to estimate costs to provide care," she explains. "If we’re doing any or all of our visit documentation in the patient’s driveway, Taco Bell drive-through, office, or at our kitchen tables, this will provide HCFA with inaccurately low-time data possibly resulting in HCFA determining future payment rates inappropriately lower than they should be," Krulish explains.
"This is a tough one as there are some visits where the documentation takes longer than the assessing and rendering of care, and that can make patients wonder if you came to see them or do your paperwork," she notes.
Are there solutions?
To make sure that time spent with a patient is correctly reported to HCFA, at Cushing (OK) Regional Home Health Agency, explains Laresa Boyle, RHIA, business office/medical records coordinator, "Our visit note has time in, time out, documentation time, and travel time. The documentation time is for any time outside the home that is spent on paperwork. Anything done in the home is considered part of their visit time."
A similar approach has been taken at Palliative CareCenter and Hospice of the North Shore in Evanston, IL. "Our visit notes and our visit day sheets both have spaces to document telephone time, documentation time, and travel time, as well as time spent in the home on the visit. It allows us to capture the actual time spent by staff much better than before we changed the notes and day sheets," says Naomi Rubinstein, RN, QA/clinical research specialist with Palliative CareCenter and Hospice.
Depending upon the state an agency operates in, differences in Medicare and Medicaid rules could eliminate the possibility that paperwork is completed outside the home. Some states, for example, require the patient to sign all documentation. Regardless of what a state might require, some agencies have taken the approach that it’s best not to even allow for a situation whereby documentation can be completed after the visit.
"One of the reasons we went to home charts is that [home care agency staff] must do the charting in the home and leave a copy in the home. The visit includes the documentation completed in the home," explains Linda Westerman, RN, MN, education director for Home Health Management Inc. in Florence, SC. Even so, she says, "they have found ways around that, too."
One way to keep employees from getting around the in-home documentation rule, Shaffer says, is by using automation. Companies such as Homeadvantage offer telephonic services. "This enables the clinicians to use the phone to track their comings and goings." She acknowledges that this system is best suited for home health aides "because the clinical documentation is not very detailed. It utilizes just a task list, so for nurses, it’s not in-depth enough. That said, it’s still a wonderful tool for payroll purposes."
Some agencies, she notes, use it for their professional staff as well, "so the agency knows they made the visit and can be alerted to the fact that paperwork will be forthcoming. It’s an excellent way of using the program because it cuts down on the aggravation of not knowing whether a patient has been seen. And it has caller ID so managers can check where a call comes from."
Using electronic methods
Thomas P. Gordon, a senior account executive with Sandata in Port Washington, NY, points out that there are several types of solutions to try if automation is an option, ranging from telephonic equipment, scanning products, and laptops or personal digital assistants. Gordon says, "[Sandata, for example], offers an automated time, attendance, and data collection system via 800-phone numbers, so there’s no cost to the patient to collect visit information, including mileage and the actual time spent in the home. In effect, we replicate the duty sheet over the telephone, and gather any and all data elements that the client needs collected. What is also nice is that you completely eliminate paper, at least for the aides, and are able to export this information directly to your payroll, billing, and scheduling software."
As Shaffer notes, "There are all kinds of vendors for point-of-care things so there is always new stuff out there — everything from laptops to handhelds, CEs [Windows, condensed], and web-based palm pilots. There really is a lot to choose from and because of this, I think agencies have the best of all worlds."
There will always be difficulties in collecting this type of data, says Gordon, "but with discipline and a little work, a more technological solution can help to ease this type of burden."
[For more information, contact:
• Laresa Boyle, RHIA, Business Office/Medical Records Coordinator, CRH Home Health Agency, Cushing Regional Hospital Home Health, P.O. Box 1409, Cushing, OK 74023. Telephone: (918) 225-2915.
• Thomas Gordon, Senior Account Executive, Sandata Inc., 26 Harbor Park Drive, Port Washington, NY 11050. Telephone: (516) 484-4400, ext 249.
• Linda Krulish, PT, MHS, President, Home Therapy Services, P.O. Box 2764, Parker, CO 80134. Telephone: (614) 250-5438.
• Diann Martin, RN, DNSc, LM Cantone and Associates, 900 Amherst, Wilmette, IL 60091. Telephone: (847) 853-8102.
• Naomi Rubenstein, RN, QA/Clinical Research Specialist, Palliative CareCenter and Hospice of the North Shore, 2821 Central, Evanston, IL 60201. Telephone: (847) 467-7423.
• Meri Shaffer, RN, Program Manager, Homeadvantage, 10875 Main St., Suite 212, Fairfax, VA 22030. Telephone: (703) 352-1830, ext 8213.
• Vicky Tataryn, RN, BS, Quality Improvement Consultant, Continuous Care Services, One Vantage Way, Nashville, TN 37228. Telephone: (615) 259-2772.
• Linda Westerman, RN, MN, Education Director, Home Health Management Inc., 1945 W. Palmetto St., Florence, SC 29502-5599.Telephone: (800) 708-7060, ext. 3050.]
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