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LPN/LVN Documentation Specialist

Home Health | Sherman, TX | Full Time

Job Description




  1. Currently licensed as practical/vocational nurse in the state of practice.
  2. Prefer 1 year of nursing experience in healthcare setting. Community/home health or medical/surgical experience is preferred.
  3. Complies with accepted professional standards and practice.
  4. Possesses and maintains good physical stamina and mental health. Has completed the agency pre-employment health clearance.
  5. Must be a licensed driver with an automobile that is insured in accordance with state and/orAgency requirements and is in good working order.
  6. Has satisfactory references from current employers and/or professional peers.
  7. Have excellent observation and communication skills.
  8. Is self-directed with the ability to work with little supervision.
  9. Is flexible and cooperative in fulfilling all obligations.
  10. Basic computer skills.
  11. Demonstrates knowledge of appropriate skills for communicating with individual ages of those served.
  12. Demonstrates an ability to work as a team member with professional and administrative personnel.
  13. Positive attitude.
  14. Excellent interpersonal and phone skills.
  15. Assertive and quick. Able to multitask.
  16. Accurate and detailed.
  17. Must possess a valid state driver’s license and adhere to all state laws while driving
  18. Must possess automobile liability insurance
  19. Must have dependable transportation kept in good working condition
  20. Must be able to drive an automobile in various types of weather/road conditions
  21. Must possess intermediate computer skills



In cooperation and collaboration with multiple disciplines, as needed, the LPN/LVN Documentation Specialist conducts clinical record audits utilizing agency policy and procedures, federal and state regulations and agency education guides. On an emergent basis, for the agency good and patient/client need, the LPN/LVN Documentation Specialist performs patient/client care visits.



  1. Provides a positive work environment by consistently modeling in a positive way, the agency philosophy, mission, values, and standards of care, and providing a professional role model for other staff. Ensures office staff and field staff are educated on process and regulatory changes.
  2. Adheres to HIPAA regulations and follows agency protocol maintaining confidentiality and does not improperly disclose of patient information.
  3. Complies with all agency policies and procedures.
  4. Is diligent in activities that ensure advanced proficiency in Homecare Homebase (HCHB) Electronic Health Record (EHR). Actively seeks out training and continuing education in agency processes including participation in offered classroom training and Web-based learning courses. Communicates as appropriate with staff, physicians, referral sources, community, patients, potential patients, caregivers, and others involved in care.
  5. As requested by the QAPI Director(s), will assist with the development, implementation and revision, as needed, of materials to meet agency policy and state and federal regulations.
  6. Provides ongoing quality documentation education and support to nursing staff according to agency policy.
  7. Complies with accepted professional standards and principles.
  8. Review all elements of the EHR including but not limited to: Plan of Care, Visit Notes, Medication Profile, Calendar (to ensure proper disciplines, frequencies, and buddy codes), Coordination Notes, Aide Care Plan (for aide services), Supply Requisition, Initial Order, Authorization Information (for non-Medicare patients), Therapy Evaluations and Re-Evaluations, Previous Orders, Physician records, etc.
  9. Reviews the EHR of offices assigned to ensure:
    1. Documentation supports patients on services meet criteria established by their payer source such as medical necessity and homebound status and ensure documentation clearly indicates the criteria are met.
    2. Documentation supports assessing clinicians and ancillary staff providing exceptional patient care by utilizing all elements of the nursing process and/or agency standards of care, and that the level of care and services provided coincide with the patients’ level of acuity and meet their needs.
    3. Documentation supports assessing clinicians and ancillary staff is providing care within their scope of practice and submits quality documentation authenticating appropriate assessment and intervention provided to the patient.
    4. Disciplines are following the established plan of care, are compliant with re-assessments within the timelines established by Medicare, providing excellent patient care, providing quality documentation, and meeting the needs of the patient. Reviews discipline only discharges to ensure frequency and goals have been met.
    5. Supervisory visits of home health aides are scheduled and performed in person, by required discipline, within timelines in compliance with federal regulations.
    6. Continuity of care and follow-up with patient/caregiver and physician(s) as indicated, ensure orders were written as necessary to accommodate patient needs, ensure meds/calendar was updated as indicated, and ensure documentation is thorough.
    7. Changes in patient health status to ensure appropriate action documented such as coordinating with physician, communicating with staff, patient, and/or caregiver, updating supply needs, and writing orders.
    8. Documentation reflects that changes/declines in patient status are reported to PCP with nursing interventions provided.
    9. Documentation reflects that proper care was provided to the patient by coordinating care with physicians and collaborating with them to update the plan of care to include additional visits, update teaching plans, etc. to meet the needs of the patient and then communicate with patient/caregiver as warranted.
    10. All clinicians’ documentation to reflect that excellent care, quality documentation, improving outcomes, and medical necessity to ensure the provision of services and documentation required for financial reimbursement for care completed on a timely basis and in compliance with state and federal regulations.
  10. Provides education to DON/Clinical Supervisor/Field staff on Quality Documentation and chart review findings.
  11. Understands priority is patient care. Must be willing to assist in whatever ways necessary to meet this goal including providing the hands on patient visits - from personal care to skilled care as needed.
  12. Ensures that QI events such as occurrences and medication errors are entered into database and that the DON is made aware. Collaborates with the QAPI Director(s) to receive direction on the further action.
  13. Ensures that documentation reflects that field staff and office staff follows protocols and take necessary action to prevent the spread of infectious diseases. Ensures infection control log is completed when necessary and that DON is made aware. Collaborates with the QAPI Director(s) to receive direction on the further action.
  14. Participates enthusiastically as a team member that actively supports the short and long-term growth objectives of the office.
  15. Participates in the Influenza Vaccination Program and QAPI activities as assigned by the QAPI Director.
  16. Participates in the Medical Review process when necessary as follows:
    1. Reviews patient/client information (OASIS, Diagnoses, Frequencies, Disciplines, Supplies, etc.) to ensure appropriate home care services are being carried out.
    2. Reviews medical records for appropriate preventative, therapeutic and rehabilitative procedures and techniques pertinent to patient/client care.
    3. Reviews medical records for accurate and relevant clinical notes regarding patient's/client's condition and care given, including physician notification and appropriate follow up.
    4. Reviews clinical records, as necessary, for communication with physicians, nurses, social workers, discharge planners and other disciplines to establish a coordinated plan of home care.
    5. Reviews medical records to ensure care is carried out as directed by the physician and patient's/client's medical diagnosis, medications, procedures and plan of care are appropriate to patient needs.
    6. Communicates findings to Branch DON/Regional Director for educational purposes.
    7. Reports review findings on all chart reviews to the Medical/Clinical Review Director for final approval and submits records to the proper entities as directed.

Disclaimer: The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities and will be directed by their QAPI Director(s) as the need arises.


  1. General office.
  2. Work is moderate with a combination of sitting, standing, and walking.
  3. Community and client home environment.
  4. Potential exposure to blood and/or body fluids and infectious disease during the performance of job duties.
  5. Potential exposure to extreme temperature and humidity when traveling and while in client homes.
  6. Potential exposure to dust, gas, fumes, and odors during traveling.
  7. This position has been designated as clinical management (see Infection/Exposure Control Plan). Employees performing clinical management duties may be involved in potential exposure to blood borne pathogens and other potentially infectious materials. All clinical management employees will be offered Hepatitis B vaccination at no expense to the employee.



  1. Visual and manual dexterity is required
  2. Good physical stamina and mental health is required. Has completed the agency preemployment health clearance.
  3. Ability to perform tasks involving physical activity, which may include heavy lifting and extensive bending and standing.
  4. Ability to deal effectively with stress.


Must meet the required continuing education hours for state certification as a nurse in Texas as applicable. Agency personnel are expected to participate in appropriate continuing education as may be requested and/or required by their immediate supervisor. In addition, agency personnel are expected to accept personal responsibility for other educational activities to enhance job related skills and abilities. All agency personnel must attend mandatory educational programs.


I have read, and fully understand all information in the above job description. I meet the stated job qualifications, and am mentally and physically able to perform the responsibilities and duties of the above job description.