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Organizing Medical Records:
Home Health Records
Legal nurse consultants will find that Home Health records have some categories, such as OASIS assessments, that other organizations don't have. As with all medical records, Home Health charts are organized first by category and then in chronological order. LNCs can use the categories below to organize Home Health records or modify the order to fit individual preferences.
Administration
Insurance information, including insurance verification intake (referral) and Medicare secondary payer worksheet
Consents, including release of information and photo consents
Re-certification information
Living Will. Although this form may have been signed prior to the intake, it can be placed behind documents from the intake date.
Durable Power of Attorney. This form may also have been signed prior to intake.
Authorization for Payment
Patient rights
Plan of Treatment
Physician Orders
OASIS Assessments, including discharge OASIS with progress summary
Supervisory Visits
Clinical Notes
Nursing
Rehab (Physical Therapy, Occupational Therapy, Speech Therapy)
Home Health Aide
Notes from Other Disciplines.
Labs / X-Rays / EKGs / Other Tests
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