Home Health Care Charting Policy & Procedures

Charting serves as proof that services have been provided. Home health care agencies maintain state-mandated policy that requires the completion, review and filing of charted services. The procedure for charting is required of and performed by home health care providers.

Reference

• Refer to the plan of care when charting services provided.

  A plan of care is a document derived from a consulting nurse's assessment. Assigned tasks for client-based services listed within the plan of care serves as a source of reference in charting.

Forms

• Forms for charting are handled by home health care agencies and home health care providers.

  Service forms are prepared by home health care agencies for the purpose of charting services provided. Such forms are then distributed to the home health care provider.

Function

• Home health care providers manage active service forms.

  While service forms are in use, home health care providers have such paperwork in their respective possession. Providers then take the service forms to and from their clients' homes on each day of assigned service.

Considerations

• Service forms are designed to accommodate approved tasks.

  The home health care industry refers to clients' service needs as tasks. Printed on each set of service forms, in accordance with state and home health care policy, are the approved tasks that home health care providers can provide for clients.

Identification

• Charting met needs

  Upon completion of assigned service needs, as identified within a plan of care, home health care providers will chart the tasks. Charting will be applied directly to the service forms, by way of indicating those categories that corresponds with referenced needs, along with dates and times.

Time Frame

• Complete the charted service form

  On either a monthly or semimonthly basis, the home health care provider completes the charted service forms. The completion process includes tallying indicated columns, along with the signatures of the client or client's authorized representative, and the provider. After the forms are completed, the provider will make a copy for his or her file, while delivering the original to the home health care agency.