Documentation in Home Care

This course is designed to assist the Physical Therapist and Occupational Therapist in understanding the unique aspects of documentation in home care. Further, it introduces the many aspects of developing a plan of care from assessment through discharge. Specific home care rules and regulations regarding documentation and staff supervision in this setting will also be included in this course.

This is a self-paced course with optional knowledge check quizzes after each lesson. These non-graded quizzes allow you to check your understanding of the lesson objectives before proceeding to the next lesson. After the final lesson you will be required to take the final exam. You must score 80% or higher to pass the course and obtain a certificate of completion.

  • Explain the common terms, rules and regulations in home care documentation
  • List the components of the plan of care
  • Describe when verbal orders should be written in home care
  • Define and document homebound status
  • List the disciplines/roles in home care and the services they may provide
  • Define and document rehabilitation potential
  • Identify the duties and documentation of PT supervision of PTA, OT supervision of COTA, and supervision of the home health aide
  • Explain how supplies and DME needs are managed and documented in home care
  • Identify caregiver roles in home care
  • Explain the basics of the Outcome and Assessment Information Set (OASIS)
  • Determine when discharge from home care is appropriate
Contact Time

2 contact hour(s) based on 60 minute contact hour

Estimated Time

The estimated time for completion for this activity is 2 hours

Intended Audience

This course is designed to meet the continuing education requirements of Physical and Occupational Therapists.

Course Planning Team

Kathy Richie, BSN, RN, Margaret Harris, MS, Iona Kaye (Katie) Barton, PT, Ed. D, MEPD, Michelle Olson, M.S.P.T.

Disclosure Statements:

Commercial Support: This course was developed in accordance with ANCC Commercial Support Guidelines. No commercial support was accepted for the development of this course.

Non-endorsement of Products and Off Label Use: This course provides a balanced view of therapeutic options. Use of generic names is always considered before using trade names. Consequently, if trade names are necessary, when available, we will use trade names from several companies. RCTC and the course planning team do not endorsed any products or drugs that may be mentioned in this course.

Author Originating

Iona Kaye (Katie) Barton - PT Ed. D MEPD

Katie received both her Bachelors of Science in Physical Therapy and her Masters of Education in Professional Development from the University of Wisconsin - La Crosse. She received her Doctorate in Education Leadership from Saint Mary's University in Minneapolis, MN. Katie was an adjunct instructor for the physical therapy program at the University of Wisconsin - La Crosse for 17 years. She has a varied background of healthcare experience including birth-3, hospital based pediatrics, school based PT, SNF PT, and most recently, 6+ years as a physical therapist for a hospital based home care and hospice agency.

Michelle Olson - M.S.P.T.

Michelle received her Bachelors of Science in Biology from the University of Wisconsin - La Crosse and her Masters of Science in Physical Therapy from Carroll College. She has been practicing as a physical therapist for a hospital based home care and hospice agency for the past 8 years and has had experience in sports medicine and pediatric home and clinic based care. Michelle has a special interest in physical therapist education and has also been employed as a lab assistant/associate lecturer at the University of Wisconsin - La Crosse for the past 5 years. Michelle is an APTA certified clinical instructor and has been taking students into the home care setting for the past 6 years.


Materials used in connection with this course may be subject to copyright protection. Retention of the materials for longer than the class term, unauthorized further dissemination of the materials, or use of copyrighted materials in any way other than intended for this class is prohibited by Copyright and Teach Act laws.


This course was developed with Rochester Community and Technical College's Continuing Education and Workforce Development Division located in Rochester Minnesota. Development was funded from the Minnesota State Colleges and Universities System.

Course Code
Course Category
Professional Health