Home Health Therapy Documentation Templates & Examples

home health documentation templates

When I started working as a home health Physical Therapist, I looked everywhere for home health documentation examples.  

I entered the world of home health from an outpatient clinic, so finding efficient ways to document in the home health setting was difficult at first.

When I figured out the basic outline of a good home health eval, daily note progress note and discharge, I decreased my documentation time by 50%.

It saved me at least an hour each day, which is a big deal when you’re paid per visit.

In this article, I’ll share how I created my own home health templates and share how much time they’ve saved me.

Home Health Documentation Examples 

The amount of time it takes to write home health physical therapy documentation (and occupational therapy documentation) will vary depending on the type of note you’re writing.  Most therapists eventually come up with some sort of home health template or system to save time when documenting their treatment, but if you’re new to home health, it’s hard to know what to expect!

Creating Home Health Documentation Example Templates

If you’re fortunate to know a therapist at your home health agency who is willing to give you a few of their templated phrases or examples, that’s a huge time saver!

But it can be really kind of awkward asking another therapist if you can have a copy of their personal ‘home health documentation cheat sheet.’  

They’ve probably spent hours creating their own unique documentation phrases and they might hesitate giving them to you for various reasons. 

When I started as a home health therapist, I made meticulous notes from the therapists who trained me and used their examples to create my own documentation cheat sheets which included:

  • Full Home Health Narrative Notes
  • Evaluation Summaries
  • Physician Verbal Order Templates
  • Treatment Note Examples / Flowsheets
  • Assessment Phrases & Discharge Summaries
  • Entire Therapy Documentation Examples 

I spent weeks organizing my notes and creating home health templates that worked for me.  For almost an entire year, I kept refining my cheat sheet and created my own little system. 

home health documentation template

So was it worth it?  ABSOLUTELY! 

Using my own home health documentation templates, I was able to save 5 to 10 minutes per patient each day.

Just to give you an idea, I might see 5 to 6 patients on a regular day: 2 evals, 3 follow up visits, and a discharge. So saving 10 minutes per patient was an entire hour saved each day! 

Since I’m paid per visit, saving time is critical, especially since I’m not paid an hourly rate to do my notes!

I highly encourage you to take a few weeks to create your own home health templates, but if you want a copy of my entire documentation template, you can find the bundle here

Therapy Documentation Example Time Estimates:

Start of Care – Plan to spend at least 1.5 hours with the patient and 1.5 hours completing the note after the visit. Start of care documentation takes the longest, especially with the newest OASIS changes. 

Evaluation – Plan to spend at least 1 hour with the patient and up to 45 minutes after the visit to complete the evaluation note. 

Visit Note – For regular follow up visits, plan to spend 30 to 60 minutes with the patient and up to 20 minutes to complete the ‘daily note.’  If you’re efficient, you can often complete the entire note during the home health visit!

Reassessment Note – In Home Health therapy, reassessments are basically like a progress note and take a little longer than a regular visit to complete.  Plan to spend 45 to 60 minutes with the patient and up to 20-30 minutes to complete a reassessment note. 

Discharge Notes – Plan to spend 30 to 60 minutes with the patient for a discharge visit and an additional 30 minutes after the visit completing the documentation.  An OASIS discharge will take longer to complete than a non-OASIS discharge

Download the Home Health Documentation Templates

If you’re a new home health therapist, this guide will save you time and headache as you can actually spend more time focusing on the patient’s needs and treatment.

If you are a veteran home health therapist, this guide can give you fresh ideas on ways to efficiently document your treatments.

Here’s what’s included in the Home Health Documentation Template:

  • Initial Evaluation Summary Example
  • Physician Verbal Order Examples and Script Template
  • Objective Measurement Handout
  • Daily Note Assessment & Documentation of Treatment
  • Progress Note Statements on Goals
  • Discharge Summary Examples
  • Goal Setting Template and Examples

The assessment phrases and narrative note examples are enough to save you at least 5 minutes per patient. With 6 patients a day, that saves you 30 minutes each day.

Therapy Documentation Template Bundle

I mentioned that I spent an entire year crafting my templates and creating a system that saved me time. You can see the entire system in the bundle below, which includes:

  • Assessment Templates
  • Goal Templates
  • Treatment Flowsheets
  • Stick Figure Exercises – A huge time saver for home health therapists!
therapy documentation bundle

What is your time worth in the evening? Personally, I would have paid over $100 to someone for their documentation templates if it would save me over 3 hours a week in documentation headaches! 🙂

Start your home health career off right with the first and only home health template documentation guide available online. Written by a therapist, for therapists.

Tim Fraticelli, DPT Physical Therapist

Tim Fraticelli is a Physical Therapist, Certified Financial Planner™ and founder of PTProgress.com. He loves to teach PTs and OTs ways to save time and money in and out of the clinic, especially when it comes to documentation or continuing education. Follow him on YouTube for weekly videos on ways to improve your financial health.