February 5, 2002 Feature

Home Care Documentation

Home health is a unique setting with its own Medicare documentation requirements. Good clinical documentation of home health eligibility, home health visits, and goal-oriented charting are essential to reimbursement for speech-language pathology services.


There are three primary criteria for eligibility for Medicare home health therapy services. Most other third-party payers follow the same guidelines.

  • Homebound status. The patient is homebound if he or she experiences an inability to leave home.  Leaving home must require the patient to expend considerable and taxing effort. Patients with psychiatric conditions may be considered homebound if the illness manifests in a refusal to leave home or if it is unsafe for the patient to leave home unattended. Homebound status is not affected by frequent absences from home when the reason to leave is to seek medical treatment. The patient may also leave home infrequently for non-medical reasons such as an occasional trip to the barber/beauty shop or to attend church. If homebound status is not documented appropriately, charges are often denied.

Here are some examples that justify home health services:

Patient requires maximum assistance of one to ambulate short distances of 10-15 feet with a walker before becoming fatigued.

Patient exhibits decreased endurance secondary to ongoing chemotherapy. Balance is unsteady and patient is unable to safely negotiate the five steps necessary to get out of the home.

  • Skilled services. Skilled services are those that are medically reasonable and necessary to the treatment of a patient's illness or injury. Skilled therapy services must be provided by a certified speech-language pathologist or under the supervision of a certified SLP.
  • Reasonable and necessary. Amount, frequency, and duration must be reasonable. Services must be consistent with the nature and severity of the patient's condition and result in improvement in a predictable period of time.

Goal-Oriented Charting

Another important part of the documentation process is the development of clear and appropriate goals. Here are some pointers:

  • Goals should be patient-focused. Write the goal in terms of what you want the patient to achieve.
  • Goals should be clear and concise. Use simple words and phrases.
  • Goals should be observable and measurable. Specify the behavior the patient will exhibit to help measure the effectiveness of your intervention.
  • Goals should be time limited. Set long- and short-term goals, and identify each on the treatment plan.
  • Goals should be realistic. Assess the home environment, family and caregiver support, and available resources.
  • Goals should be agreeable to both patient and therapist. Allow the patient to participate in goal development. This allows for the validation of expectations

Home Visit Documentation

The following are tips to ensure that you effectively document your home care treatment sessions.

  • Paint a picture of the current status of the patient, the treatment provided, and the patient's response to treatment.
  • Identify why the patient needs or continues to need home health services.
  • Use the plan of care to guide your interventions and your documentation. Address the goals and interventions on each visit. 
  • Document each time you teach the patient, family, and/or caregivers.
  • Specify the plan for the next visit. Confirm your expectations for the next visit with the patient to make sure you are in agreement.
  • Note clinically significant observations and state them objectively. Avoid documenting judgments. Remember that this is the patient's chart.

Rebecca B. Skrine, is the rehabilitation services manager at Baptist Hospital East Home Health Agency in Louisville, KY. Contact her by email at rskrine@bhsi.com.

cite as: Skrine, R. B. (2002, February 05). Home Care Documentation. The ASHA Leader.

Test Your Medicare IQ

Match the letters and the numbers:

1. What is homebound status?
2. What is a physician referral?
3. What is non-billable time?
4. What is a clarifying order?
5. What are skilled services?
6. What is skilled care?

A. Time spent preparing materials for carriers and intermediaries or on denial appeals.
B. Services that are medically reasonable and necessary to the treatment of a patient and which must be provided by a qualified professional.
C. The type of care that must be demonstrated in Medicare documentation.
D. This is defined as when a person is unable to leave home or cannot do so without considerable and taxing effort.
E. Medicare requires one of these prior to furnishing speech-language pathology services to a beneficiary.
F. A document required when a significant change is made to the patient's plan of treatment. 

Answers to Medicare quiz:
1-d;  2-e;  3-a;  4-f;  5-b;  6-c

Documentation Requirements for Medicare Reimbursement

What to Record for Assessment and Plan of Treatment in All Settings

Medical History

  • Date of onset/exacerbation
  • Prior functional status
  • History of previous treatment and outcomes, if any
  • Homebound Status (home health only)

Plan of Treatment

  • Type of therapy/procedures
  • Frequency and duration
  • Diagnosis
  • Functional goals (short-term)
  • Outcome (long-term)

If your facility is accredited by JCAHO, there are additional requirements that must be met. Check with your facility administrator to review the JCAHO accreditation manual or discuss your facility's compliance plan.


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