Home Health Documentation Guide 2026
Master home health documentation with comprehensive guidance on OASIS assessments, Medicare compliance, skilled nursing notes, homebound status requirements, and Plan of Care (485) documentation.
Complete templates, examples, and best practices for home care nurses, therapists, and aides.
Types of Home Health Visits
Understanding different disciplines and their documentation requirements in home health care.
Skilled Nursing (SN)
Most common home health visit
Common Services:
- Wound assessment and care
- Medication management and teaching
- IV therapy and injections
- Vital signs monitoring
- Catheter care
- Disease education
- Patient/caregiver training
- Coordination of care
Documentation Focus: Must demonstrate skilled need and progress toward goals
Physical Therapy (PT)
2-3x/week typical
Common Services:
- Gait training
- Strength and balance exercises
- Transfer training
- Fall prevention
- Pain management
- Post-surgical rehabilitation
- Home safety assessment
- Assistive device training
Documentation Focus: Document functional improvements and progression
Occupational Therapy (OT)
1-3x/week typical
Common Services:
- ADL training (bathing, dressing)
- Upper extremity strengthening
- Cognitive assessment
- Energy conservation techniques
- Home modifications
- Adaptive equipment training
- Fine motor skills
- Safety awareness
Documentation Focus: Focus on functional independence in ADLs
Speech Therapy (ST)
1-2x/week typical
Common Services:
- Swallowing assessment (dysphagia)
- Speech/language therapy
- Cognitive-linguistic therapy
- Communication strategies
- Diet modification training
- Caregiver education
- Voice therapy
- Aphasia treatment
Documentation Focus: Document swallow safety and communication progress
Home Health Aide (HHA)
Daily or several times/week
Common Services:
- Personal care (bathing, grooming)
- Assistance with dressing
- Meal preparation
- Light housekeeping
- Medication reminders
- Vital sign monitoring
- Ambulation assistance
- Observation and reporting
Documentation Focus: Document tasks completed and patient response
Medical Social Work (MSW)
As needed, typically 1-2x/episode
Common Services:
- Psychosocial assessment
- Community resource coordination
- Financial counseling
- Advance directive discussion
- Caregiver support
- Crisis intervention
- Adjustment counseling
- Discharge planning
Documentation Focus: Document psychosocial barriers and interventions
OASIS Assessment Documentation
The Outcome and Assessment Information Set (OASIS) is required for Medicare home health certification. Key sections and documentation requirements.
M1000 - Demographics
- •Patient name, demographics
- •Emergency contact
- •Primary caregiver
- •Living situation
- •Payer information
Pro Tip: Verify all demographic information at start of care
M1021-M1033 - Diagnosis
- •Primary diagnosis (reason for home health)
- •Secondary diagnoses
- •Comorbidities affecting plan of care
- •ICD-10 codes required
- •Payment diagnosis grouping
Pro Tip: Primary diagnosis must justify skilled need and homebound status
M1200-M1242 - Vision, Hearing, Speech
- •Vision impairment
- •Hearing ability
- •Speech and language
- •Frequency of pain
- •Pain interference with activity
Pro Tip: Document use of assistive devices (glasses, hearing aids)
M1306-M1324 - Pressure Ulcers
- •Pressure ulcer risk assessment
- •Number and stage of ulcers
- •Most severe stage
- •Unstageable pressure injuries
- •Presence of stasis ulcers
Pro Tip: Use clock position for wound location; measure accurately
M1400-M1730 - Functional Status
- •Grooming
- •Bathing
- •Dressing upper/lower body
- •Toileting
- •Transferring
- •Ambulation/locomotion
- •Feeding/eating
- •Medication management
Pro Tip: Score based on what patient DOES, not what they could do with help
M1800-M1870 - Elimination
- •Urinary incontinence
- •Urinary catheter
- •Bowel incontinence
- •Ostomy status
Pro Tip: Document frequency and continence management strategies
M1910-M2102 - Medications
- •Drug regimen review
- •Medication follow-up
- •High-risk medications
- •Multiple medications
- •Influenza/pneumococcal vaccines
Pro Tip: Complete medication reconciliation at every assessment
M2200-M2420 - Care Management
- •Therapy needs
- •Emergent care
- •Fall risk assessment
- •Discharge disposition
- •Influenza received
Pro Tip: Document therapy necessity to support discipline frequencies
OASIS Submission Timeframes
- • Start of Care/Resumption: Within 5 days of SOC/ROC date
- • Recertification: Within 5 days before or after recertification date (every 60 days)
- • Discharge: Within 2 days of discharge for Medicare quality reporting
- • Transfer: Within 2 days when patient transfers to inpatient facility
- • Significant Change: As soon as change is identified and assessment completed
Medicare Home Health Requirements
The four core requirements for Medicare home health coverage and how to document them correctly.
Homebound Status
Criteria:
- Leaving home requires considerable and taxing effort
- Unable to leave home without assistance (person, device, special transportation)
- Normal inability to leave home
- Leaving home is medically contraindicated
Allowable Absences:
- ✓Medical appointments
- ✓Adult day care (health-related)
- ✓Religious services
- ✓Occasional family events
Documentation Best Practice
Must document specific limiting condition and assistive needs at each visit
Skilled Need
Criteria:
- Requires skills of licensed nurse or therapist
- Services must be reasonable and necessary
- Complexity requires professional skill
- Patient/caregiver unable to safely perform
Examples:
- →Wound care requiring sterile technique
- →IV medication administration
- →Patient teaching requiring professional assessment
- →Injections
- →Medication management for unstable patient
Documentation Best Practice
Link skilled service to specific medical condition and complexity
Physician Order (Plan of Care - 485)
Criteria:
- All services ordered by physician
- Signed and dated by physician
- Certification within 30 days of start of care
- Recertification every 60 days
Must Include:
- *Diagnoses
- *Specific orders for disciplines
- *Frequency and duration
- *DME/supplies needed
- *Medications
- *Goals
- *Rehabilitation potential
Documentation Best Practice
Obtain physician signature within regulatory timeframes
Face-to-Face Encounter
Criteria:
- Required within 90 days before or 30 days after start of care
- Must be performed by physician or allowed NPP
- Must be related to primary reason for home health
- Certifying physician must document
Who Can Perform:
- •Certifying physician
- •Physician NPP (PA, NP, CNS)
- •Acute/post-acute care physician
- •Telehealth encounter allowed
Documentation Best Practice
Document date, provider, and clinical findings related to home health need
Skilled Nursing Visit Note Example
A comprehensive example demonstrating proper documentation of skilled nursing services, homebound status, and progress toward goals.
Skilled Nursing Visit
78-year-old female, CHF, diabetes, stage 3 sacral pressure ulcer
Subjective
Patient reports feeling "much better" today. States breathing has improved with new medication regimen. No chest pain or palpitations. Some ankle swelling noted in evenings. Rates pain at wound site 3/10, improved from 5/10 last visit. Reports compliance with low-sodium diet and fluid restriction. Daughter present and assists with medications. Patient ambulating to bathroom with walker independently. Reports slight dizziness when rising quickly. Denies falls since last visit. Home environment: Clean, well-maintained. Adequate lighting. Bathroom grab bars installed per PT recommendation. Medication box filled for week by daughter. No safety concerns noted today. Caregiver: Daughter visits daily, assists with medication management and meal preparation. Reports mother is more alert and engaging in conversation.
Objective
Vital Signs: - BP: 138/82 (sitting), 128/78 (standing) - orthostatic check negative - HR: 78, regular rhythm - RR: 18, unlabored - O2 Sat: 94% on room air - Temp: 98.2°F - Weight: 162 lbs (down 3 lbs from last week - fluid loss) - Blood glucose (fingerstick): 142 mg/dL (fasting) Cardiovascular: Heart rate regular, no murmurs auscultated. Bilateral lower extremity edema 1+ (improved from 2+ last week). Pedal pulses 2+ bilaterally. Capillary refill <3 seconds. No JVD. No dyspnea with conversation. Respiratory: Lungs clear to auscultation bilaterally, no crackles or wheezes. Breathing unlabored. No accessory muscle use. O2 saturation adequate on room air. Skin Assessment - Sacral Pressure Ulcer: - Stage: 3 (unchanged) - Location: Sacrum, midline, 3cm superior to coccyx - Size: 3.2cm x 2.8cm x 1.1cm depth (decreased from 3.5cm x 3.0cm x 1.3cm) - Wound bed: 80% granulation tissue (improved from 60%), 20% slough - Exudate: Minimal serous drainage - Periwound: Pink, intact, no maceration or erythema - Odor: None - Treatment: Cleansed with normal saline, applied calcium alginate, covered with foam dressing - Turned patient to assess wound, educated on pressure relief every 2 hours Medications: Reviewed medication list with patient and daughter. All medications present and organized in weekly dispenser. Patient verbalizes understanding of purpose and side effects of: - Furosemide 40mg daily (diuretic for CHF) - Metoprolol 50mg BID (heart rate/BP control) - Lisinopril 10mg daily (BP/heart failure) - Metformin 1000mg BID (diabetes) - Aspirin 81mg daily (cardiac protection) Functional Status: Ambulates with walker 20 feet without shortness of breath. Transfer sit-to-stand with minimal assistance using walker. Uses bedside commode at night to conserve energy.
Assessment
1. Congestive Heart Failure (I50.9) - Improving - Decreased edema, improved weight loss indicating diuresis - BP controlled, no dyspnea at rest - Compliance with medication regimen and diet - Continue current management 2. Type 2 Diabetes Mellitus (E11.9) - Fair control - Fasting glucose 142 (slightly elevated) - Patient reporting compliance with diabetic diet - Continue monitoring and education 3. Pressure Ulcer Stage 3, Sacral (L89.153) - Improving - Wound size decreased by 15% since last measurement - Increased granulation tissue - Clean wound bed with minimal drainage - Continue current wound care protocol - Good compliance with pressure relief 4. Homebound Status: Confirmed - Requires walker for ambulation - Taxing effort to leave home - Orthostatic precautions due to dizziness - Currently unable to attend medical appointments without assistance 5. Skilled Nursing Need: Continues - Complex wound care requiring assessment and sterile technique - Medication management for unstable CHF and diabetes - Patient education for chronic disease management - Cardiovascular monitoring Patient progressing toward goals. Anticipate continued skilled nursing 2x/week for 3 more weeks.
Plan
Skilled Nursing: 1. Continue wound care per protocol: Normal saline cleanse, calcium alginate, foam dressing 2. Monitor wound weekly for healing progression (size, depth, tissue type) 3. Continue cardiovascular assessment: vital signs, edema, breath sounds, weight 4. Diabetes monitoring: Weekly fingerstick glucose, diet reinforcement 5. Medication management: Continue review and education at each visit 6. Patient education: - Pressure relief techniques (turn every 2 hours while in bed) - Signs/symptoms of CHF exacerbation (increased SOB, weight gain >3lbs in 2 days, worsening edema) - Low-sodium diet adherence (<2000mg/day) - Fluid restriction (1500mL/day) - Orthostatic precautions (rise slowly) 7. Caregiver education: Continue wound care teaching for daughter, medication management Coordination: - Communicate with physician regarding wound improvement and CHF stability - Continue PT for strengthening and fall risk reduction - HHA services 3x/week for bathing assistance Next SN Visit: 12/21/2026 (3 days) - wound care, vitals, diabetes monitoring Safety: Patient and caregiver educated on emergency signs requiring 911 call (chest pain, severe SOB, confusion). Emergency numbers posted on refrigerator. Home safety adequate. Time spent: 60 minutes (30 min direct care, 30 min documentation/coordination) Supplies used: Normal saline, calcium alginate dressing, foam dressing, sterile gloves, glucometer strips Electronically signed: [RN Name], RN Date/Time: 12/18/2026 14:30
Home Health Aide Visit Note Example
Documentation requirements for HHA services including tasks completed and patient observations.
Home Health Aide Visit
Date: 12/18/2026Home Health Aide Visit Note Date: 12/18/2026 Time: 9:00 AM - 10:15 AM (75 minutes) Tasks Completed: ✓ Bathing: Complete bed bath provided. Patient tolerated well, no complaints of pain or discomfort. ✓ Oral care: Teeth brushed, dentures cleaned. Mouth appears clean, no lesions noted. ✓ Hair care: Hair shampooed and combed. ✓ Dressing: Assisted patient with dressing in clean clothes (sweatshirt, sweatpants). ✓ Toileting: Assisted to bedside commode x2. Continent of bowel and bladder. ✓ Skin care: Applied lotion to dry skin on lower extremities. Turned patient to check pressure points - sacral wound covered with dressing (not changed per protocol). No redness noted on heels or hips. ✓ Vital signs: BP 135/80, HR 76, RR 18 - reported to RN via phone ✓ Ambulation: Walked patient 15 feet to chair with walker. Steady gait, no loss of balance. ✓ Meal preparation: Prepared breakfast (oatmeal, banana, tea). Patient ate 75% of meal. ✓ Medication reminder: Reminded patient to take morning medications. Observed patient take pills from dispenser. ✓ Linen change: Changed bed linens, patient linens soiled from night sweats. Observations: - Patient in good spirits, conversational and alert - Breathing normal, no coughing or wheezing - Skin warm and dry, good color - Moving all extremities - Slight swelling in ankles (reported to RN) - Appetite fair, taking fluids well - Daughter present during visit, no concerns expressed Patient Response: Tolerated all care well. No complaints. Patient stated "I feel clean and refreshed, thank you." Problems/Concerns: None noted. Home clean and organized. Adequate supplies. Next scheduled visit: 12/20/2026 at 9:00 AM HHA Signature: [Name], HHA Supervisor notified: Yes ☐ No ☒ (routine visit, no concerns)
Plan of Care (485) Documentation
Essential elements required on the CMS 485 Plan of Care form for Medicare certification.
Patient Information
- Full name, DOB, Medicare number
- Address and phone
- Primary caregiver
- Emergency contact
- Primary physician
Certifying Physician
- Physician name and NPI
- Physician signature and date
- Face-to-face encounter date
- Face-to-face encounter provider
Diagnoses
- Primary diagnosis (with ICD-10)
- All secondary diagnoses affecting care
- Surgical procedures if applicable
- Date of onset for primary condition
Discipline Orders
- Skilled nursing (frequency/duration)
- PT, OT, ST if ordered (frequency/duration)
- HHA (frequency/duration)
- MSW if ordered
DME and Supplies
- All durable medical equipment
- Wound care supplies
- Diabetic supplies
- Oxygen if applicable
Medications
- Complete medication list
- Dose, route, frequency
- PRN medications
- Recently changed medications
Functional Limitations
- Homebound status justification
- Activities permitted
- Weight-bearing status
- Mental/cognitive status
Goals
- Measurable, time-specific
- Patient-centered
- Realistic and achievable
- Related to skilled interventions
Safety Measures
- Fall precautions
- Infection control
- Emergency plan
- Dietary restrictions
Critical Timeline: 485 Physician Signature
The Plan of Care (485) must be signed by the physician within 30 days of the start of care date. Failure to obtain timely signature can result in denial of all claims for that certification period.
Track signature deadlines carefully and follow up with physician offices proactively. Document all attempts to obtain signature.
Common Denial Reasons & How to Avoid Them
The most frequent causes of Medicare home health denials and strategies to prevent them.
Patient Not Homebound
Common Documentation Errors:
- Documentation shows patient leaving home frequently
- No assistive device documented
- Patient drives to medical appointments
- Attends non-medical activities regularly
How to Avoid:
- ✓Document specific limiting condition at EVERY visit
- ✓Describe assistive needs (walker, wheelchair, oxygen)
- ✓Document taxing effort required to leave home
- ✓Note who assists when patient leaves home
- ✓Clarify medical vs. non-medical absences
Services Not Skilled
Common Documentation Errors:
- Documentation shows routine, non-complex care
- Patient/caregiver could perform service
- No professional assessment or judgment needed
- Teaching without evidence of complexity
How to Avoid:
- ✓Link service to specific medical complexity
- ✓Document skilled assessment at each visit
- ✓Describe why professional skill is required
- ✓Show changing medical status requiring RN judgment
- ✓Document unsuccessful attempts by patient/caregiver
No Progress Toward Goals
Common Documentation Errors:
- Same documentation visit after visit
- No functional improvement noted
- Goals not measurable or time-specific
- Maintenance therapy without skilled need
How to Avoid:
- ✓Document incremental progress (measurements, function)
- ✓Update goals as patient improves or declines
- ✓Show objective changes (wound size, vital signs, ambulation distance)
- ✓Adjust plan when patient plateaus
- ✓Justify continued skilled need even if maintaining
Inadequate Face-to-Face Documentation
Common Documentation Errors:
- F2F date outside allowed window
- F2F not related to primary home health need
- Physician failed to document encounter
- No attestation on 485
How to Avoid:
- ✓Verify F2F date is within 90 days before or 30 days after SOC
- ✓Ensure physician documents connection to home health need
- ✓Include F2F date and provider on 485
- ✓Obtain attestation from certifying MD
- ✓Keep copy of F2F documentation in chart
Missing or Incomplete OASIS
Common Documentation Errors:
- OASIS submitted late
- Responses inconsistent with clinical notes
- M items skipped or incorrectly coded
- No change between assessments when clinical notes show change
How to Avoid:
- ✓Submit OASIS within required timeframes
- ✓Ensure OASIS matches clinical documentation
- ✓Code based on what patient DOES, not potential
- ✓Review OASIS for completeness before submission
- ✓Document rationale for coding decisions
Plan of Care Not Signed Timely
Common Documentation Errors:
- 485 not signed within 30 days of SOC
- Missing physician signature on recertification
- Orders don't match services provided
- No discharge summary when patient discharged
How to Avoid:
- ✓Track 485 signature deadlines carefully
- ✓Follow up with physician office proactively
- ✓Ensure verbal orders are signed within 30 days
- ✓Match visit frequency to 485 orders
- ✓Document attempts to obtain signature
Home Health Documentation Best Practices
Essential tips for compliant, comprehensive home health documentation.
Homebound Status
- Document at EVERY visit - homebound status can change
- Be specific: "Patient requires walker and assistance of daughter to ambulate to car"
- Note the effort: "Patient becomes dyspneic after 20 feet, requires rest breaks"
- Mention medical contraindications: "Physician ordered strict weight-bearing precautions"
- Document allowable absences: "Patient attended nephrology appointment with medical transport"
Skilled Need
- Link every intervention to medical diagnosis and complexity
- Use "skilled" language: assess, evaluate, teach, manage, monitor
- Document your clinical judgment and decision-making
- Show why service requires professional skill
- Note changes requiring skilled intervention
Progress Documentation
- Use objective measurements (wound size, vitals, ambulation distance)
- Compare to previous visits: "Edema decreased from 3+ to 1+"
- Document functional improvements: "Patient now transfers independently, was min assist"
- Note patient/caregiver learning: "Daughter demonstrates correct wound care technique"
- Explain lack of progress if patient declining or plateaued
Coordination of Care
- Document all communication with physician, therapists, other providers
- Note MD orders received and changes to plan of care
- Document medication changes and who ordered
- Show collaboration between disciplines
- Include caregiver involvement and education
Automate Home Health Documentation with AI
PatientNotes AI streamlines home health documentation by automatically capturing visit details, generating compliant skilled nursing notes, ensuring homebound status is documented at every visit, and reducing documentation time by 30-45 minutes per visit.
Frequently Asked Questions
Common questions about home health documentation answered.
What is OASIS and when is it required?
OASIS (Outcome and Assessment Information Set) is a comprehensive assessment required by Medicare for all adult home health patients. It must be completed at Start of Care, Resumption of Care, Recertification (every 60 days), significant change in condition, Transfer to inpatient facility, and Discharge. OASIS data is used for payment (case-mix), quality measures, and outcomes reporting. Non-Medicare patients may not require OASIS depending on payer requirements.
How do I document homebound status correctly?
Document homebound status at every visit by noting: (1) The specific medical condition limiting mobility (e.g., CHF causing dyspnea, fracture with weight-bearing restrictions), (2) What assistance is needed to leave home (walker, wheelchair, oxygen, person), (3) The taxing effort required (shortness of breath, pain, fatigue after minimal distance), and (4) Who assists when patient does leave home. Document allowable absences like medical appointments, religious services, or adult day care. Use specific details, not general statements.
What is the face-to-face requirement for home health?
Medicare requires a face-to-face encounter between the patient and a physician or allowed NPP (physician assistant, nurse practitioner, clinical nurse specialist, or certified nurse midwife) within 90 days before or 30 days after the start of home health care. The encounter must be related to the primary reason for home health. The certifying physician must document this encounter and attest to it on the Plan of Care (485). Telehealth encounters are permitted.
What makes a service "skilled" for Medicare home health?
A skilled service requires the skills of a licensed nurse or therapist due to complexity, required assessment, or need for professional judgment. Examples include: wound care requiring sterile technique and assessment, IV therapy, medication teaching for complex regimens or unstable conditions, management of unstable chronic conditions, post-surgical care, rehabilitation requiring professional skills. The key is documenting WHY the service requires professional skill - the complexity, changing condition, or safety concerns that prevent the patient or caregiver from safely performing the task.
How often should I complete OASIS assessments?
OASIS is required at specific time points: (1) Start of Care - within 5 days of SOC date, (2) Resumption of Care - within 5 days after inpatient stay, (3) Recertification - every 60 days ±5 days, (4) Other Follow-up - for significant change in condition, (5) Transfer - when patient transfers to inpatient facility, and (6) Discharge - at end of care. The assessment window is critical for payment and quality reporting.
What should be included in a skilled nursing visit note?
Every skilled nursing visit note should include: (1) Subjective data - patient/caregiver report, (2) Objective findings - vital signs, physical assessment, wound measurements, (3) Assessment - diagnosis review, progress toward goals, homebound status, skilled need justification, (4) Plan - interventions performed, education provided, coordination of care, next visit plan. Also document: visit date/time, visit number, services provided, supplies used, time spent, safety assessment, and caregiver involvement.
How can I avoid Medicare denials for home health?
To avoid denials: (1) Document homebound status at every visit with specific details, (2) Clearly link all services to medical diagnosis and skilled need, (3) Show measurable progress toward goals with objective data, (4) Ensure face-to-face encounter is documented and timely, (5) Submit OASIS accurately and on time, (6) Obtain physician signatures on 485 within 30 days, (7) Match services provided to orders on 485, and (8) Use specific, detailed documentation rather than generic statements. Review notes from payer perspective - would an auditor understand the medical necessity?
Can AI help with home health documentation?
Yes, AI documentation tools like PatientNotes can significantly streamline home health documentation by automatically capturing visit details, generating skilled nursing notes, ensuring all required elements are included (homebound status, skilled need), prompting for OASIS-relevant information, and maintaining consistency across visits. This saves 30-45 minutes per visit and reduces documentation errors that lead to denials. AI can also help with OASIS coding accuracy by identifying relevant clinical information.
Related Resources
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