Charting that gets paid vs. charting that gets denied
Every home health note quietly answers the question: why did a skilled clinician need to be here? The left column shows what auditors want to read. The right column is what most denials look like.
| Do — shows skilled need | Don't — reads as routine |
|---|---|
| Assessed dyspnea on exertion; SpO₂ dropped from 96% to 89% after 20-ft ambulation; instructed pursed-lip breathing and paced recovery. | Patient stable. Tolerated visit well. |
| Wound measured: 2.1 × 1.4 × 0.3 cm, decreased from 2.6 × 1.7 × 0.5 last visit; granulation tissue present; no signs of infection. Continued current dressing protocol. | Wound is healing well. No issues. |
| Patient requires rolling walker and contact-guard assist of one to ambulate 20 ft; SOB after crossing room; unable to navigate 4 front steps without significant assistance. | Patient is homebound. |
| Reconciled medications; identified duplicate metoprolol prescription (one from PCP, one from cardiologist); contacted PCP, awaiting clarification. | Reviewed medications with patient. |
| Instructed daughter (primary caregiver) in two-person transfer technique using gait belt; daughter performed return demonstration safely on second attempt. | Educated patient on safety. |
| Patient demonstrated 4/10 accuracy with insulin draw-up; re-instructed using a step card; will reassess next visit. | Diabetic teaching provided. |
| Goal not yet met: independent stair negotiation. Skilled PT continues to address impaired dynamic balance and quad weakness limiting safe step-over-step pattern. | Patient is doing the exercises. |
| BP 168/96, asymptomatic. Held next dose per protocol. Notified Dr. Lin; new order received to add lisinopril 10 mg daily. Patient and spouse instructed on new med. | BP elevated. Will monitor. |
Verbs auditors look for
Skilled need shows up in the verbs you choose. The "Do" column above is built on these:
- Assessed · Evaluated · Reassessed — clinical judgment in action.
- Identified · Recognized — your finding, not the patient's report.
- Instructed · Taught · Trained · Re-instructed — patient or caregiver, with response.
- Adjusted · Modified · Progressed — the plan changed because of what you saw.
- Notified · Coordinated · Reported — communication that affected the plan.
- Measured · Documented · Monitored — concrete observations, not impressions.
Words and phrases to retire
- "Tolerated well." Says nothing about what you did or what changed.
- "Stable, no changes." The fastest path to a denial. Show why you were needed.
- "Patient educated on…" — without naming what they understood, demonstrated, or struggled with.
- "Continue plan of care." Reads as autopilot. Justify why skill is still needed.
- "Homebound." Don't assert it. Paint the picture that makes it obvious.
One rule to remember
Write like the reader has never met your patient and is deciding whether to pay for the visit — because that's sometimes literally true. Show your work, name your verbs, paint the picture.
Adapted from Home Health Charting Basics on Home Health 101.