LNCtips.com: Organizing Home Health Medical Records

Most home health records are now in electronic format. The easiest way to organize electronic records is to leave them in order. In other words, no organization is necessary.

With paper medical 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