What documentation is required for home health care (HHC) for patients needing assistance with activities of daily living (ADLs)?

Documentation Requirements for Home Health ADL Assistance

For Medicare-covered home health services providing ADL assistance, you must document: (1) physician certification of homebound status, (2) physician orders specifying the need for skilled nursing or rehabilitation services concurrent with home health aide services, (3) a comprehensive assessment demonstrating functional limitations in specific ADLs, and (4) a plan of care signed by the physician. 1, 2

Core Documentation Components

Physician Certification and Orders

• The physician must certify that the patient is homebound and requires intermittent skilled nursing care, physical therapy, or speech-language pathology services 1
• Document that the patient cannot attend outpatient services due to mobility limitations, unstable medical status, or multiple comorbidities 1, 2
• Medicare reimburses for personal care (ADL assistance) only if skilled nursing or rehabilitation services are also required as determined by the physician's evaluation 1
• The physician order must specify which skilled services justify the home health aide coverage 1

Functional Assessment Documentation

• Document specific ADL impairments using standardized assessment: bathing, dressing, toileting, transferring, continence, feeding, and grooming 1, 2
• Record whether the patient requires "some help," "unable to perform," or can perform independently for each ADL 1, 2
• Include IADL assessment: using transportation, managing money, taking medications, shopping, preparing meals, doing laundry, doing housework, using telephone 1
• Document gait speed if applicable (≥4 seconds indicates need for physical therapy referral) 2

Medical Justification Criteria

Document at least one of these qualifying conditions from the American Thoracic Society recommendations 1:

• Patient diagnosed with new disease or has multiple comorbidities
• Unstable or fragile medical status requiring close supervision and frequent cardiopulmonary assessment
• Patient has functional limitations and requires assistance with ADLs such as bathing or IADLs such as food shopping
• Patient is older, living alone, and/or has no support system
• Patient cannot attend outpatient services and needs monitoring and/or education
• History of more than one emergency room visit or urgent hospital admission in the past year

Home Environment and Safety Assessment

• Document home safety evaluation findings: problems with stairs, bathtubs, rugs, lighting 1, 2
• Record environmental modifications needed: handrails, adequate lighting, removal of loose rugs 2
• Assess and document fall risk factors and history 1, 2

Caregiver and Social Support Documentation

• Identify and list all available caregivers in the medical record 1
• Document caregiver capacity to meet care needs and any limitations 1
• Record whether patient is living alone or has inadequate support systems 1, 2
• Document caregiver anxiety, confusion, forgetfulness, or poor coping skills if present 1

Discipline-Specific Referral Documentation

When to Document Need for Skilled Nursing

• Patient has active comorbid conditions and high risk of complications beyond the respiratory system 1
• Requires care coordination for multiple services 1
• Needs medication management with new or multiple medications 1

When to Document Need for Physical/Occupational Therapy

• Primary problems involve deconditioning, impaired mobility, or need for home adaptation 1, 2
• Patient requires adaptive equipment provision for eating, dressing, or bathing 2
• Gait and assistive device evaluation needed 2

When to Document Need for Home Health Aide

• Primary need is assistance with basic ADLs (bathing, dressing, toileting, transferring) 1, 2
• Patient requires personal care services but only if skilled nursing or rehabilitation is also documented 1
• Limited chore services needed within context of personal care delivery 1

Critical Documentation Pitfalls to Avoid

• Do not document home health aide services alone without concurrent skilled nursing or therapy justification — Medicare will deny coverage 1, 2
• Do not use vague language like "needs assistance" — specify exact ADL impairments and level of assistance required (standby, minimal, moderate, maximal, total) 1, 2
• Do not omit homebound status documentation — this is mandatory for Medicare coverage 1
• Do not delay documentation of equipment needs — early adaptive equipment provision prevents complications 2
• Do not provide generic recommendations — tailor documentation to the specific discharge living environment with structural barriers noted 2

Plan of Care Documentation

• Develop and document a comprehensive discharge plan addressing medical stability, respiratory status (if applicable), psychological readiness, and home environment preparedness 1
• Document specific goals for ADL improvement or maintenance with measurable outcomes 1
• Include caregiver education plan for range of motion, positioning, and proper use of assistive devices 2
• Record frequency and duration of each service type (skilled nursing, therapy, home health aide) 1