Marrelli T M, Hilliard L S
Marrelli and Associates, Inc., Health Care Consultants and Publishers, Westerville, Ohio, USA.
Home Care Provid. 1996 Jul-Aug;1(4):198-201. doi: 10.1016/s1084-628x(96)90102-1.
The creation of effective home care documentation serves many important purposes. From a payor perspective, such as Medicare, the clinical documentation can provide the basis for covered care. On the other hand, poor documentation can raise questions about medical necessity and even eligibility criteria, such as the patient's homebound status. Documentation can either support payment for covered services or begin the cycle toward increased requests for information and more-focused medical review processes. The following discussion provides key tips, information, a comprehensive checklist, and outcomes examples that support the creation of "best practices" for home care organizations related to clinical documentation.
创建有效的家庭护理文档有许多重要目的。从付款方（如医疗保险）的角度来看，临床文档可为承保护理提供依据。另一方面，文档记录不佳可能会引发关于医疗必要性甚至资格标准（如患者的居家状态）的问题。文档既可以支持对承保服务的支付，也可能开启获取更多信息请求和更有针对性的医疗审核流程的循环。以下讨论提供了关键提示、信息、全面的清单以及结果示例，以支持家庭护理组织创建与临床文档相关的“最佳实践”。
