Home Health Tip: Nursing Documentation

Nursing documentation is required to include the inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals. Physician orders for nursing services must contain what intervention is to be performed, frequency and indication of end point when applicable. When completing the nursing documentation, include documentation that the intervention that was ordered took place. Make sure skilled care is evident on each note, that each note is signed and dated as well as visits being consistent with the physician orders.