looking for daily assessment forms for skilled nursing medicare residents

  1. I recently accepted a position in a top notch high census LTC facility. I am currently having to do narrative notes with each resident for my head to toe assessment. Can anyone tell me where I could find several different forms, in hopes of compiling one to fit the needs of my residents. Any suggestions would be greatly appreciated. I am new to the long term care setting. Although I have 20 years experience in nursing. Sometimes I feel like I have just got out of school, so many of the rules and regulaions are very different than the hospital setting.
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  3. by   CapeCodMermaid
    Get a Briggs Company catalogue....they have a form for everything you can imagine. If you need a cheat sheet for daily skilled notes, it's probably just as easy to make one yourself. And this is about the only time in LTC you can use common sense...if the person was admitted for care s/p ORIF, you need to document the wound, the level of pain, the ADL status, response to therapy....if they were admitted for pneumonia then you'd document temp, any antibiotics,lung sounds, 02 sats....no need to do a head to toe note every day for Medicare..
  4. by   CapeCodMermaid
    Last edit by CapeCodMermaid on Mar 15, '05 : Reason: link didn't work
  5. by   robin_mds_nurse
    We go over what needs to be charted at our weekly Medicare meeting for the SNF residents, and the skilled charge nurses come & take notes. But it is still an ongoing problem. CapeCod is absolutely right in that you need to chart according to what skilling service you are providing. If they are receiving OT/PT, what amount of assistance they require for ADL's, ambulation & transfers, etc. It is next to impossible to do a MDS without good charting from the nurses, and if you get a denial from Medicare, you have to have good notes to back up the MDS/RUG score to get reimbursed. ~Robin