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

[AmyB]

At our LTC, we chart on Medicare residents qshift with a complete set of vitals as well as an assessment included. I try to always include how well they eat meals during my shift, how they ambulate (wc, walker, unassisted, etc.), respiratory status, and any other significant occurances during my shift.

It does take a long time to complete all the charting. Yesterday, I had about 6 Medicare residents and it took me over an hour just to get everything written - not counting assessment time.

Hope this helps. Best wishes!

Amy

[CoffeeRTC, BSN, RN]

From what I understand, and we've been doing this for years, charting just needs to be daily and should be focused on the skilling need. If it is pt/ot....chart about ADLs, transfters, etc. Every facility does it different. We don't do daily vitals on our medicare residents and split the charting between 7-3 and 3-11. You just need to justify why the resident is being skilled. That is alll that they are looking at when doing reviews. Supportive documention for the skilling need. We've never had denials or problems with this.

[Nascar nurse, ASN, RN]

I am the "medicare" nurse for our facility and am responsibile for regulation compliance as well as following up on any ADR's we get. Medicare requires DAILY skilled nursing documentation. It needs to pertain to why they are being skilled. IE; if admitted with CHF - assess lung sounds, SOB, fatigue w/ therapy?, need for more frequent rest periods w/ ADLs/therapy?, edema, weight gain, etc. Hip fractures; ie: pain management, complainance w/ weight bearing, lovenox/coumadin use and signs of adverse effects, etc. We do daily vitals with the medicare documentation schedule.

[mickeypat]

My next ? is this... do you do vitals on the medicare residents every shift? And do they need to be documented on EVERY shift? 'Cause at night, it's generally the same... unless I do something different with that resident.

Just looking for ideas to help ease the work load a little with being short staffed...

[CapeCodMermaid, RN]

Medicare regs-document once a SHIFT for the first 72 hours after admission, then ONCE a day after that. Vitals once a shift x 72 hours then once a day. We chart them with the notes and split the notes between 7-3 and 3-11. And, as Nascar said, you have to document on their skilled needs....Medicare doesn't care if they are "pleasant, ate well." If they have a new hip or a new knee, what does the joint look like? level of pain? anticoagulant therapy..progress with rehab....

[CoffeeRTC, BSN, RN]

Hmmm, we never take vitals q day on the medicare pts.

[mickeypat]

Heck... we have to do vitals EVERY SHIFT on our medicare residents and they are suppose to be documented on EVERY SHIFT, many nites I get to chart "resting quietly with eyes closed. Denies pain or discomfort." Most of the other charting is done on the other shifts. They see what they do and are doing.

Sad part is is that we chart in at least 3 places a shift on each of our medicare residents and sometimes more if we have all of these flow sheets that have to be done ie: pain control, feeding tubes, colostomy.. etc.....

[lisalake]

Most facilities require q-shift charting on Medicare residents, although the I believe the regs are daily...this usually ensures adequate documentation is recorded for the skilled service being provided. Many times this is repetitive, but if there is a review, it is necessary. Besides, most Med A residents are not skilled for just one shift; your doing physical assessments, monitoring for pain, behaviors, doing treatments...etc...take credit for what you do and document; it's important; for the resident and facility reimburstment.

[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.

[Nurse_Pauline]

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.

[Nascar nurse, ASN, RN]

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.