Medical necessity documentation in every home health skilled service visit is, well a necessity. This simple outline lists the required elements for each clinical visit note using statement directly from the Medicare Benefit Policy Manual Chapter 7, 40.1.1. It's just reformatted for easier reference. Go ahead, look it up!
Review these rules whenever tempted to write "Continue with POC" or "Goals: Ongoing" or "Discharge plan: When goals met."
Make your skilled service visits billable! Buy one and share as many copies as you'd like within your own agency.