One important part of running a home health agency, or any healthcare company, is ensuring your patient care staff are providing accurate documentation for the care and condition of clients. Ensuring charting is achieved and that your staff is compliant with charting requirements could be a challenge. Read on for some tips for charting compliance among staff.

Help Them Understand Why

If an employee is more aware of why charting is so important, they will be more likely to take it seriously and chart well. There are many reasons for charting – legal reasons and liability, billing and getting paid by insurance and tracking the patient’s condition.

If your company bills for treatment or care, but there isn’t proper documentation of that treatment or care, there could be trouble and that money could have to be paid back. Documentation also protects the company and providers from liability issues.

Charting isn’t just important from a business perspective. It really matters for quality patient care. Having an adequate chart for a patient is the best way to see how their condition has changed, and to be able to look at what has helped or hindered their progress. It’s important to have a record of what treatments they’ve had and what education has been given. It can help providers make decisions on what care to give them next.

User-Friendly Interface

If the charting system is user-friendly, you will be much more successful with how well your employees chart. If an agency’s home health software is confusing and difficult to use, they may become frustrated and cut corners. Healthcare workers have a lot of responsibilities on their plates, and you want to make it easy for them to not drop the “charting ball”.

Adequate Training

The Initial Training is Key

Help each new staff member by having really great training regarding charting. Starting a new patient care job can be overwhelming, as it comes with many new responsibilities. Be sure that your charting orientation is helpful by making it efficient and understandable.

Make your requirements for charting clear and concise. It’s possible that your staff doesn’t need to chart more, but that it would be useful for them to chart more efficiently. Be clear on what information needs to be documented for each patient.

Be sure that during training and orientation, each new employee has ample time to learn the charting system, company requirements for documentation, and has time to practice and get used to charting.

Ongoing Training

Once your staff is initially trained, ensure they have resources available to help them chart successfully. Some may find a physical list of charting requirements for certain scenarios helpful. For example, a list of what needs to be charted for a patient upon admit, a list for discharge, a list for routine visits, lists for different diseases or conditions, lists for different procedures. Having a collection of guidelines to refer to for multiple scenarios gives employees some helpful and concrete assistance.

Perhaps in addition to physical reference materials, employees can get help from a manager, or have someone who is assigned to help with charting, who they can call if they aren’t sure what documentation is needed or how to chart it. Consistently including charting reminders in periodic meetings could also be helpful.

Auditing

It’s possible that having employees audit one another’s charts could increase charting compliance. One study found that nurses who both received charting education and were assigned to audit other people’s charting had better charting compliance for pain, homebound status, and skilled nursing notes.

Employees could be assigned to some charts to audit each week or each month and get paid for their auditing time. Not only will it double-check other staff’s work, but it can also help enforce for them how to correctly chart.

Goals & Incentivize

Help staff set goals to achieve charting requirements. Goals could be set with individuals or in a group. Consider ways you can incentivize your staff to achieve goals and chart correctly. One fun idea is to have a monthly prize. Each person who achieved all charting requirements or goals for the month is put in a drawing to win the prize. You could also reward each person individually with a prize or bonus.

Follow up with staff who are struggling to hit their charting goals and offer individualized help to those who need it. Discover what barriers to charting compliance your staff may be facing and carefully consider how to remove those barriers.

Communicate with staff optimistically and give positive feedback. Let them know when they’re doing a good job. They will feel rewarded when you express appreciation for their efforts to do their jobs well. Let them know that their hard work doesn’t go unnoticed.

Helpful links/Sources

Combs, T. (2020, April). The Importance of High-Quality Clinical Documentation Across the Healthcare Continuum. Journal of Ahima.

Guthiel, T. (2004, November). Fundamentals of Medical Record Documentation. Psychiatry (Edgmont), 1(3), 26-28.

Nelson, S., & Walden University. (2015). Nursing Staff Participation in Chart Audits Increases Documentation Compliance. ProQuest Dissertations Publishing.