Medicare Charting

[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

[CapeCodMermaid, RN]

huh? I chose my name not to extol my female gender but because my father used to call me a mermaid ...never wanted to get out of the water. I suppose if I had been a boy he might have called me a merman...merboy, but I doubt it.

[missqueenqann]

Go to your MDS nurse and ask he/she if you can see the MDS manual. This book will help you greatly in your charting. Great way to increase revenue for your company. Take credit for what you do in nursing.

[blondegenes]

Charting and vitals on medicare patients every shift should be a BIG RED FLAG.

[NurseLoveJoy88, ASN, RN]

We have a medicare documentation flow sheet where we check off the assessment data. I.E. lungs clear ( check mark). We do vitals q shift and write a short nurses note. Thankfully we only have a few but I agree it is time consuming.

[king_of_the_hill_fan]

Why is charting and VS q shift on medicare a big red flag? We do it at our SNF. Just did it tonight, in fact.

[arrianeRN]

yes,we do charting every shift too! i work noc shift and there's only 2 nurse's on the floor.Our census now is 98.I'm pretty scared cause i have to take care of 48 patients, 25 are medicare,plus my weekly summaries. Writing down these patients vital signs and doing medicare charting at the same time takes me forever!

[zieglarf, LVN]

VS and charting q shift for ours. It a little worksheet where we can document the VS and check off boxes about pain, bowel/bladder, heart rate, vision, etc... the back side has nurses notes where we chart.