Legal Aspects of Home Care Documentation

Course Code: REL-PAC-0-LAHCD

Hours: 1

Type: Online Course

Content Expiration Date: 12/31/2025

Learning Objectives:
Outline the purpose of documentation in home healthcare.
Explain how to use best practices to create compliant documentation.
Describe how reimbursement requirements and regulatory standards affect documentation in home healthcare.

Outline:
Section 1: Introduction

About This Course

Learning Objectives

Documentation Matters

Obstacles to Good Documentation

Form of Communication

Regulatory Standards

Reimbursement Requirements

Malpractice

Quality Improvement

Review

Summary

Compliant Documentation

Methods for Documenting

Timeliness

Accuracy and Completeness

Writing Clear Notes

Patient Refusal

Incident Reports

Wound Documentation

EMRs

Handwritten Medical Records

Abbreviations

Other Practices

Review

Summary

Patient-Driven Groupings Model

Medicare Reviews

Required Documentation

The Face-to-Face Encounter

Coverage for Skilled Nursing

Observation and Assessment

Managing the POC

Teaching and Training

Venipuncture

Home Infusion Therapy

Conditions of Participation (CoPs)

Patient Rights

Plan of Care

Professional Standards

Coordination of Care

Comprehensive Assessment

Drug Regimen Review

Review

Summary

Section 5: Conclusion

Summary

Course Contributor

Resources

References

Congratulations!

Instructor: Jennifer W. Burks, M.S.N., R.N.

Jennifer has over 30 years of clinical and teaching experience, and her areas of expertise are critical care and home health. She is certified as an OASIS Specialist- Clinical (COS-C) and is a Curriculum Designer in post-acute care for Relias. She earned her Bachelor of Science in Nursing from The University of Virginia in 1993 and her Master of Science in Nursing from The University of North Carolina, Greensboro in 1996. Her professional practice in education is guided by a philosophy borrowed from Florence Nightingale’s Notes on Nursing, “I do not pretend to teach her how, I ask her to teach herself, and for this purpose, I venture to give her some hints.”

Target Audience:
The target audience for this course is: Nurses; in the following settings: Post-Acute Care.

Relias Learning will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.

Relias Learning has a grievance policy in place to facilitate reports of dissatisfaction. Relias Learning will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias Learning at support@reliaslearning.com.

All courses offered by Relias Learning, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.

To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.

Course Delivery Method and Format
Asynchronous Distance Learning with interactivity which includes quizzes with questions/answers, and posttests.