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CLINICAL DOCUMENTATION &
ELECTRONIC CHARTING

  • Visit Documentation should be submitted within 48 hours of the visit.

  • Visit confirmation via Teams (from the Care Coordination staff) will include a link with specific instructions for required documentation for that visit. If you are not sent this information, please ask. Pay for each visit is dependent upon accurate and timely submission of documentation per these instructions.

  • Admission visits should be no less than 1 hour of visit time.

  • Follow-up visits should be no less than 30 minutes of visit time.

  • The HHC Visit Note Portal is the required method for clinical charting and electronic submission of clinical documentation. 
     

visit NOTE portal
ADVANTAGES OF ELECTRONIC CHARTING

  • Not an app; nothing to download

  • Accessible from any device (mobile phone, tablet, PC, or Mac) with an internet browser & login

    • Optimized for use on a mobile phone

  • Paper-free charting, signatures, and submission

  • Paper-free corrections, revisions and re-submission process

  • Guided instructions, tips and validation logic as you complete the form (reduces correction requests)

  • Ability to attach supplemental paperwork, pharmacy forms and/or pictures as needed

  • Ability to Pause & Save records, then Edit & Resume at later time, prior to submission

  • One-click to submit visit notes, with immediate confirmation and visibility

    • No more back-and-forth sending pictures via Teams (or email or fax)

    • No more wondering if your notes were received or if they have been processed/approved

  • Secure, HIPAA compliant Nurse Portal for each RN to login:

    • Real-time access to visit status (not yet submitted, pending review, revisions requested, or approved)

    • Email notification when your visits are approved or revisions are requested

    • Access to historical data and your previous visit submissions

 

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visit NOTE portal
Frequently asked questions

Q: Does HHC provide a tablet/device for using the portal?

A: No, the current expectation is for HHC nursing staff to use their existing cellular device (smart phone) to complete documentation via the portal. The visit documentation portal was specifically designed and optimized for use on mobile. 

Q: How much storage space does the Visit Note Portal occupy on my personal device?

A: None. The Visit Note portal is through secure online access that does not require the user to download or save anything to their personal device.

Q: How are patient/client signatures obtained?

A: Patients will sign using a stylus pen or a finger. It is our strong recommendation that you do not allow the signor to hold your device. Instead, we recommend that you place your device on a clean, stable surface or that you hold the device while obtaining signature. 

Q: How do I make sure I am provided a stylus pen and appropriate supplies for sanitizing the pen and my device? 

A: A stylus pen and alcohol wipes to sanitize the pen can be ordered from the Agency through our online supply order form. It is not recommended to use alcohol or other sanitizing wipes on any touch device. As recommended by most device manufacturers, when UV light sanitation is not available, the exterior surfaces of touch devices should be cleaned with a cloth mildly dampened by soapy water or 70% alcohol.

Q: What if my device is damaged while charting is being done? 

A: You are responsible for the proper use and protection of your device at all times. You should not give your device to a patient/client or place your device on an unstable or unclean surface. Maintaining control and protection of your device while charting should prevent any damages from occurring.

Q: Is there any reimbursement for using our personal device to chart electronically? 

A: No. At this time use of the electronic charting option within the Visit Note Portal is an optional convenience for our nurses, and only submission via the Portal is required. In the future, if electronic charting becomes required, the Agency will consider a compensation structure that reflects this expectation and requirement.


Q: What about my patients that have forms in the home that I need to submit? 

A: The Visit Note Portal allows for images and files to be uploaded with any visit record submission. The user simply scans or takes a clear picture of the paper/pages and uploads the image(s)/file(s) to the visit record.


Q: What about my patients that are with pharmacies that require specific forms in addition to or in lieu of HHC standard documentation? 

A: Nurses can complete these special forms as usual and then scan or take a clear picture of the paper/pages and upload the image(s)/file(s) to the visit record. For pharmacies that require their own forms in lieu of HHC paperwork, the user will only upload the required documentation and will not be prompted to complete HHC forms electronically.
 

Q: What if I forget to have my patient sign the visit note, consent, or education checklist?

A: During a Start of Care or Admission visit it is crucial that the nurse obtain signature on the HHC Consent form prior to providing any hands-on care. This is to ensure the Agency, Nurse and Patient are protected by our insurance and liability coverage. Failure to obtain this signature could result in disciplinary action, so please do not forget.

If you forget to obtain signature during a routine visit for an established patient, you will need to notify us via Teams by tagging @TeamHelp-VisitNotes.

 

*Forgetting to obtain signature should be a rare occurrence. Nurses with a pattern of forgetfulness will be required to travel back to the patient's residence to obtain signature without additional compensation for travel.

HHC ADMISSION PACKET

  • Admission visits should be documented as no less than 1 hour of visit time.

  • START OF CARE / ADMISSION PACKET:

    • Page 1: CONSENTS & AUTHORIZATIONS

      • Must be signed prior to providing hands-on care

      • Patient/Client signature Required

    • Page 2: ADMISSION NOTE

      • Patient/Client signature Required

    • Page 3: ADMISSION ASSESSMENT

    • Page 4: ADMISSION EDUCATION ACKNOWLEDGEMENT

      • Only check the applicable training elements

      • Patient/Client signature Required

    • Page 5: MEDICATION PROFILE

    • Page 6: ADMINISTRATION RECORD *Required if Applicable

      • Required when the RN is infusing a specialty medication or giving a 1st dose

      • Not required when teaching a patient to self-infuse

      • Vitals must be taken and documented per protocol

DOWNLOAD

HHC Admission Packet

HHC STANDARD CLINICAL NOTE

  • Documentation for all subsequent (non-admission) visits:

    • Page 1: STANDARD CLINICAL NOTE

    • Page 2: ADMINISTRATION RECORD *Required if Applicable

      • Required when the RN is infusing a specialty medication or giving a 1st dose

      • Not required when teaching a patient to self-infuse

      • Vitals must be taken and documented per protocol

  • Visit time should be no less than 30 minutes.

DOWNLOAD

HHC Standard Clinical Note

HHC NON-STANDARD NOTE

On occasion, you will travel for a visit that cannot be appropriately documented with our standard clinical forms. In order to receive compensation you will need to submit a non-standard visit note.

  • SUPPORT VISIT - You provided hands-on clinical support (e.g. PIV start or Port access) to another RN who performed patient care and completed clinical documentation for the visit. Relevant clinical details should be provided in the narrative.

 

  • SHADOW VISIT - You attended a visit to observe and receive training from another RN who performed patient care and completed clinical documentation for the visit. Summary of training elements and observations should be detailed in the narrative.

 

  • TRAINING VISIT - You attended a visit to provide training and education to another RN who performed patient care and completed clinical documentation for the visit. Summary of training elements and observations should be detailed in the narrative.

 

  • NO SHOW VISIT - You traveled and arrived to a patient's residence to find that patient was not available for scheduled care. *These visits are only paid if the Agency and/or the RN confirmed the visit.*

 

  • INCOMPLETE VISIT - You were unable to provide care as ordered due to unforeseen reason(s) including clinical status contradictory to scheduled infusion. *These visits are only paid if the Agency confirmed the visit and/or the RN confirmed the visit and presence of medication within 48 hrs*

 

  • SPECIMEN VISIT - You dropped-off a specimen container and / or picked-up a patient-collected lab specimen as required & related to infusion therapy orders and services. Documentation must include patient vitals & a detailed narrative regarding patient education and proper collection of the specimen. This form is not acceptable for lab draw visits.

DOWNLOAD

HHC Non-Standard Note

DOWNLOAD LINKS 
HHC & PHARMACY FORMS

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