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Clinical Documentation: Keeping Your Agency Out Of Hot Water And The Courtroom!

courtroomLet’s talk about the real issues with clinical documentation. In today’s home health and hospice world it is much more than regulations. It is also much more than taking care of the patient. We live in a very litigious society. As an agency owner or administrator, it is important to make sure documentation can stand up in a courtroom. 

4 Tips To Clinical Documentation: 

Nurses and therapists go into the field to take care of people. If your documentation process does not leave a clear and consistent path from admission to discharge, then change workflow. Here are 4 things to help you streamline the process. 

  • Clear Care Plans: Any clinician in that discipline should be able to interpret the interventions regardless of whether the clinician has a homecare background. If this is not the case, then you can’t really show your care plans are effective treating disease process or patient care. 
  • Don’t Omit Important Data: Every licensed professional has heard “If you didn’t document it, then you didn’t do it”. In the healthcare world there is no truer statement. If deposed on patient care, then your documentation is your only guide. You can’t defend your agency or the individual clinician if there is no record of a phone call made or intervention completed. 
  • Consistency: Documentation should be completed in a consistent pattern. Provide clear education to clinicians as to the flow of documentation. Vague documentation is a nightmare. It will always favor the person taking action against the agency. Clearly state interventions and make a clear consistent way for clinicians to document them. 
  • Policies Matching Clinical Practice: If your clinicians document care that is contrary to policy, then the clinician sets herself up for potential malpractice and your agency can’t it. Best practices need maintained and that means your employees need to know how to follow your policies. In addition, review your policies and procedures to ensure it is not so strict that clinicians cannot possible comply. A beautiful policy manual is no good if clinical documentation can’t comply with it. 

Let Us Be Your Guide To Clinical Documentation:

At Kenyon Homecare Consulting, we specialize in clinical and operational processes with senior associates who can streamline and teach documentation. Call us today at 206-721-5091 or contact us online to see how we can put all the pieces of the documentation puzzle fit. 


Who Checks The Oasis Assessments In Your Agency? What Are You Doing With The Data You Receive? Doing Nothing Is Like Having A Brain Unattached From The Rest Of The Body.

Oasis TrainingOk,  it’s time to focus on Oasis assessments. The Oasis is clearly a data collection tool for CMS, but most agencies do not use it properly. Today, incorrect assessments can mean a big difference financially. So, we need to discuss the work flow in your office and how to maximize use the assessment tool.

Reviewing Your Oasis:

Do you have someone reviewing the assessment tool? Is that individual Oasis certified? It may be that you utilize a vendor to sweep for discrepancies. Ultimately, someone needs to review that tool for accuracy. The person needs to be Oasis certified and capable of comparing clinical information with what is contained in the assessment tool.  This is not only for clinical accuracy, but the difference in Oasis mistakes can mean so much money left on the table for every episode.

Maximize Educational Opportunities:

This one is big. If you don’t analyze the data you receive from the reviews, then it makes no sense. You will continue to see the same consistent mistakes from the same clinicians. This costs you more money in the long run. Take the Oasis errors and work with the individual clinicians as well as with entire clinical staff.  When Oasis teaching is consistent there is improvement in accuracy. Accuracy declines can lead to increases in ADRs or other types of audits.

Once your staff has consistent levels of accuracy, then focus on linking the Oasis to proper care planning. Often times, the assessment tool is filled out, but never looked at throughout the episode of care. It should be key in writing interventions and goals based upon what the tool should look like at discharge. Too often, this is not the case. If this sounds familiar to you, then educate staff to use the tool as an ongoing guide to care plan management.

Let Kenyon Homecare Consulting Be Your Guide:

At Kenyon Homecare Consulting, we have senior consultants who are certified in Oasis as well as coding to guide clinicians through the documentation process. Allow Kenyon to complete 5 free reviews on current assessments and codes in your system. You may see you are missing out on reimbursement and accuracy. Contact us today at 206-721-5091 or contact us online to see how we can help!