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Documentation Compliance

Ilya Vakhutinsky

June 5, 2020

Documentation Compliance

If you’ve worked in healthcare for a little while, you already know the saying “if you don’t document it, it didn’t happen.” Documentation is crucial for all healthcare organizations, including agencies throughout the home care industry. However, documentation compliance can be tricky for even the most veteran home care agency leaders. After all, with caregivers spread across the community serving clients in their homes, checking up on documentation habits and follow-up can seem nearly impossible. 


If your agency is struggling with documentation compliance, or if you want to make sure it doesn’t become an issue with your team, here are a few best practices that can keep everyone on track.


Explain the Importance of Documentation 


Your staff, especially your caregivers and nurses, have been documenting since they first started in the healthcare space. However, most of them don’t necessarily know why documentation is crucial to your clients and your agency. Take time to empower your staff with knowledge about documentation by incorporating a brief section into your orientation training as well as your ongoing training curriculum. 


Let your staff know that accurate and consistent documentation is important because:


  • It provides leaders with updated information to better communicate with family members 
  • It leads to increased reimbursement rates from CMS and insurance companies 
  • It can prevent hospitalizations and can help leaders catch signs of illness before it becomes a crisis 
  • It helps the care plan become a living document, updated with the client’s most recent needs, challenges, and preferences 


Consider Online Documentation Platforms


Home care leaders face a specific challenge when it comes to documentation: caregivers are not near a nursing station packed with paper or electronic charts that can make documentation easier to track. Instead, caregivers are in client homes with paper care plans that may not have been updated for weeks or months. If your agency is not already using a platform or software that gives caregivers the chance to document online via an app or secure website, now is the time to seriously consider investing in new technology.


Platforms that allow for secure documentation offer caregivers and leadership staff:


  • The opportunity to read an updated care plan for each client
  • The ability to track hydration, urine output, ADLs, range of motion exercises, behaviors, and more right on the caregiver’s smartphone
  • Increased compliance with documentation as the agency leaders can input required documentation parameters so that caregivers know exactly what to document about
  • Documentation review in real-time
Best Practices, Policies and Procedures


With the right education and tools, caregivers are more likely to remain compliant with daily documentation. Further, the right tools and education can help them to follow best practices of client care including reviewing the care plan prior to the beginning of their shift. You can further ensure documentation compliance by adapting these policies and practices within your agency:


  • Start a Mentor program, where new caregivers are paired with veteran caregivers and given the opportunity to shadow them for a few shifts to watch documentation best practices
  • Include 15 minutes of documentation time to the end of each shift so that caregivers are paid for extra minutes they use for documentation purposes 
  • Add a gentle alarm or chime to the caregiver app as a documentation break reminder
  • Assign leaders in the home care office to audit documentation by randomly choosing client electronic charts at least 30 minutes per week
  • Address documentation errors or bad habits immediately with the specific caregiver as well as with the entire staff during meetings or electronic communication
  • Host yearly skills review sessions for all caregivers that include a documentation education and demonstration component
  • Make documentation errors have disciplinary consequences, laid out in your employee handbook
  • Build a caregiver documentation task force that meets every few months to discuss documentation challenges they are having in the field and to brainstorm about ways to remedy those issues across the agency


Agencies with excellent documentation compliance are agencies that have worked to make accurate documentation a daily habit. You can create this culture in your agency as well.





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