General Section
SKILLED DOCUMENTATION GUIDELINES — EXPANDED
DiraChart · Clinical Reference · Read-only baseline inherited by all agencies
Compliance · 4.1
Visit-level Compliance Checklist
Module code | CMP-COMPLIANCE |
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Version | 1.0 · Population: Adult · Authoring level: DiraChart (read-only baseline; agencies may append) |
Scope | The pre-flight check run before signing a visit — the visit-level requirements, skilled-nursing justification, teaching documentation, care coordination, safety and closeout, and authentication items that map to the most-cited deficiencies in Medicare home-health audit. |
How to use this module Run this checklist before signing every visit. It is organized as six pass/fail blocks; a note that clears all six is audit-defensible. It operationalizes the Foundations discipline (necessity sentence, quantified outcomes, teach-back mastery, closed-loop coordination) and the self-contained rule — every value and finding is stated so a covering nurse who has never met the patient can act on it. Where an item references a threshold, confirm it against the current orders and plan of care. |
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This checklist is the last line of defense before a visit is signed. Each block below corresponds to a category auditors examine; the items within it are the specific things most often found missing. Treat any unchecked item as a documentation gap to close before authentication, not after.
How the six blocks map to audit Blocks 1–2 establish that the visit occurred, the patient still qualifies, and the care was skilled. Block 3 proves that teaching produced measured learning, not just activity. Block 4 proves coordination closed the loop. Blocks 5–6 establish patient safety at closeout and a valid, contemporaneous signature. |
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