Medicare Charting - page 2

by mickeypat 39,984 Views | 42 Comments

I have a question.... In your LTC facility how often do you document on your Medicare residents? What guidelines do you use? Do you do vitals on them every shift? At the facility I am currently working at we have to do... Read More


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    I think the reg in my state is vital signs shiftly for the first 72 hours, then daily, but at the facility i work at we continue to obtain vitals shiftly. We also use a skilled nursing flow sheet for our medicare pts which is like a checklist instead of writing a nurses notes. I wasnt to crazy about them at first, but its a definate time saver. The flow sheets are made by the briggs company.
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    Quote from Bird2
    We do daily charting on Medicare. Hall A is done by dayshift, Hall B by PM's. They rotate halls every week. Vitals are done daily. Every shift does charting plus vitals if the pt is on an antibiotic, had an incident, etc. With the daily Medicare charting we get more details than if the nurses are trying to chart on 26 residents every shift.
    I agree with you about getting more detail by splitting up the list. I have enough problems with nurses going into what I call "auto pilot" and just charting "blah, blah, blah". If I asked them to do everybody every shift... I would probably never get anything useful!

    We also chart every shift w/ vitals for the first 72 hours - think that is federal reg.
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    Quote from mickeypat
    I have a question.... In your LTC facility how often do you document on your Medicare residents? What guidelines do you use? Do you do vitals on them every shift?

    At the facility I am currently working at we have to do vitals on each medicare resident, document on them in their chart every shift, even though it's pretty much the same on each night shift. We now have new guidelines that we have to chart on one each resident and it takes almost an hour to do 5 residents!!!!!!! That is just nuts when we have so many other things to do!!!!!! The facility frowns on having any overtime, so we end up donating :angryfire time to the facility or get a stern talking to from management. But then there is one nurse who always is there for at least 2 hours after her shift and c/o not getting her break and that she can never get her stuff done, but never gets "yelled" at...

    Am just curious about what other facilities do for medicare... or even managed care...

    Thanks
    At our facility we also have to chart,fully assess, and do v/s's on all Medicare patients as well. I am the only nurse at noc and it is a big challenge to get it all done. I spend about 4-5 hours on documentation alone d/t 16 mdc res in our facility. I know Medicare only requires once a day but each facility or each director of nursing has their own way of doing things. I think it sucks ,but I love being a nurse.
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    At our facility we chart on our med A and part B from head to toe and anything else pertinent with full vs,every shift!!!!!!!!!
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    we have a grid set up so that every shift gets their fair share of medicare a charting, after the initial 72 hours.

    don't ever "donate" your time to the facility. what if you get hurt off the clock? you deserve to be paid for your work! the department of labor, wage and hour division would be interested in your concern.....:d
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    Initially every shift for the first 72 hours. We also use a flowsheet, designed by us that covers the entire MDS, it is more of a checklist and has spaces for comments. Narrative charting is required for anything out of the ordinary. After the 72 hours, only days/evenings do the vitals.
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    At one facility we did q shift charting for 72 hours, then twice daily for 14 days, then once a day after that. The day shift charted on the odd numbered rooms and evenings did the even numbered. Night shift did most of the edits and summaries.
    And, of course if anything out of the ordinary happened, that would be charted on, too.
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    This is not to dispute anyone’s routine. I would just like to point out that some facilities maybe doing redundant or unnecessary writing when all is required is proof that the daily skilled service was actually provided.

    Depending on the daily skilled service rendered, a nurse's note is not always the absolute source of documentation. I would like to cite examples of daily skilled services that do not necessitate supplementary nurses’ notes:

    • Rehab Therapies – what’s required is an MD therapy order, a therapist’s eval’n and therapy plan, and the daily attendance log

    • Tube Feeding – MD feeding order, Dietitian’s nutrition assm’t, a record of daily intake, the signed MAR. Besides, the skilled need for tube feeding is not determined by a daily nurse's note but by the reason for need and the amount of fluid and caloric intake.

    • Wound care - MD order for prescription medications and aseptic techniques as delineated in the TAR

    • Pressure ulcers (St III or higher or a widespread skin disorder) – MD assm't and tx order, signed TAR, a CNA assignment to turn and position resident or a care plan addressing interventions to facilitate wound healing or prevent new ones.

    When a daily skilled service is to observe and assess a patient’s unstable medical condition that can not be proven elsewhere then the nurses’ note maybe imperative. Albeit, whenever there is an actual change in status or a need to monitor a resident’s response to a new treatment, the standard of practice dictates the event/s should always be documented, regardless the service is skilled or not.

    This link is from a NY FI (yours may vary) that delineates the sources of information they will request as proof of daily skilled services (see p2) http://www.empiremedicare.com/traina/manual/PET0452.pdf

    I know it’s hard to uproot an old habit. But if the current routine works for you… heck, go for it.:wink2:
    Pooksmom1996 and Rexie68 like this.
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    Talino-
    As usual you have given us factual information and I always enjoy reading your posts. One thing I smiled at under wound care: MD assessment! HA! We assess all our wounds, describe them to the MD and tell him what treatment we want. Our MD, his PA and his NP are all sorely lacking in wound assessment skills.
    And you're right....old habits are hard to break and every facility thinks theirs is the one true way to Medicare nirvana.
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    Talino, we do not do that excessive documentation in our facility but, jsut follow what is required of the regs.


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