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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

..Katy Jones




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