Importance of Clinical Narrative and Patient Education while Documenting Home Health OASIS Assessments

Creating good quality nursing documentation in home health industry can be very time consuming and often nurses complete the paperwork at home, taking time out of personal life.

Home health agencies operate can be Medicare-based agencies and/or agencies that accept only private insurance. It has been observed that home health nursing documentation for private insurance patients is easier and less time-consuming, owing to the fact that answering the long OASIS document is not a requirement. Also, in comparison to someone in the Medicare age group, these patients have fewer health complaints due to the younger age group they are in, which means lesser documentation time. In contrast, nursing documentation for a Medicare patient would easily take at least an hour without compromising the quality of documentation.

Whether one hand-writes or uses EMR software for documentation, one deficiency that frequently come across, is with the comments section on the individual pages of the OASIS form. Often the visiting staff think that checking the boxes on the OASIS form would be enough to document a well rounded assessment. Unfortunately, just making some selections on OASIS form is not enough and nurses are meant to write additional notes in the Comments section which will help with improving the quality of the document as well as do more accurate coding.

Now, let’s see why that would not suffice with the help of 2 illustrations below.

  1. Illustration 1: If a patient is positive for congestive heart failure, though checking the box for CHF on the cardiovascular section of the assessment and marking for edema on the day of visit is important, these mere selections would not provide any information regarding the management of the condition. There are other aspects that need a mention, to complement the selection made for CHF. This includes information regarding the patient’s presentation of symptoms in recent times, such as, exacerbation of pedal edema, any evidence of fluid back up in the chest, any exacerbation of SOB lately, changes in the diuretic dose, potassium supplementation, episodes of hypotension in recent times, any dizzy episodes, recommendation for fluid limitations, compliance with the dietary recommendations, and any changes with endurance levels lately.
  2. Illustration 2: If a patient is positive for Chronic Obstructive Pulmonary Disease, just checking the box and making selection of COPD on the respiratory section of the assessment would not give a complete picture regarding the management of the condition. Adding comments regarding aspects such as, compliance/noncompliance with smoking cessation (if the patient was a smoker), varying abnormal breath sounds, knowledge regarding and compliance with pursed-lip breathing, recent changes with the patient’s lung volumes, any changes in the dose of inhalation medications, any consistent deterioration in oxygen saturation lately, any recent chest infections, and any signs and symptoms of worsening pulmonary hypertension would provide more insight, as to whether the patient’s condition is progressing or deteriorating.

Adding the clinical narrative  not only provides valuable information regarding the patient’s health but also adds more justification for the admission/recertification to home health. Without the necessary narrative,  home health nursing documentation with just check marks on the boxes for various health conditions would make no difference from one certification period to the next. These comments translate into defining your goals better and thereby, provide new guidelines for patient instructions and teachings. Good home health nursing documentation will also offer an easy and better reference with regards to the patient’s health, thus reducing the learning curve to any new visiting nursing staff, if the staff visiting the patient were to change, a situation that we frequently encounter in this industry. Also, as the progress patients make on their goals is a direct measure of your performance as a clinician, the clinical narrative made over a period of time, offer you the credit you deserve for the efforts made.

Adding clinical narrative can take unduly long time, something that maybe difficult to manage. In our experience, we found that many home health nurses struggle with this.  To alleviate the nurses from writing clinical summary, we  at Home Health Patient Education, offer self guided templates which would help saving the time for skilled nursing assessment notes, yet retaining the quality of the document. With these OASIS clinical narrative templates, nurses would hardly have the need to type any information.

We offers two products as a solution to create faster home health nursing documentation:

Dynamic Nursing OASIS Assessment templates

Our Skilled Nursing Assessment templates generate customized narratives for individual patient needs with few clicks. The narrative is generated once you click the Submit button at the end of the page. This summary could be copied and pasted into the comments section, if you use an EMR software, or copied and pasted onto an addendum sheet that you can attach to the OASIS form if you use paper documentation. This helps in making the home health nursing documentation quicker and easier.

Our nurses saved up to 15 to 20 minutes per assessment using these nursing OASIS assessment templates. If you consider doing at least 2 assessments a day, you are saving at least 30 minutes time from writing notes.

We offer skilled nursing OASIS assessment templates for – start of care, resumption of care, recertification, 60 day summary and discharge.

Patient Teachings

Another deficiency we found with documentation is in the section on patient teachings and instructions, especially medication teachings. As a home healthcare nurse, we need to educate our patients regarding their current health status and how to manage to improve it, provide them with tools which will help them meet the goals defined on their plan of care. We noticed patient teachings material for home health industry was not available in the format we usually teach or write on skilled notes. We wanted to offer some assistance to my fellow nurses on the same, by offering some patient teachings, which could be copied and pasted onto their nursing documentation. The nurses can use these patient teachings to educate their home bound patients as well. We offer nurse teachings based on different systems and commonly used medications and medication groups which can be easily incorporated into the notes. Currently we offer more than 7500 patient teachings! It included teachings on more 170 diseases and conditions and 500 medications.

With patient teachings covering most of the common ailments for home health patients, you can teach the patients about their health easily thus improving patient satisfaction.

We hope Home Health Patient Education offers our colleagues working in the industry a quicker way to complete home health nursing documentation.