Medicare Charting guidelines

renerian, BSN, RN · Dec 29, 2004

Thanks everyone for your input.

renerian

Antikigirl, ASN, RN · Dec 29, 2004

Yeah, anyone that comes back from the hospital is automatically put on "alert Charting" at my facility. THat means q shift vs with temp (if I don't put temp on there my caregivers won't take them..habit now), and a general notation in charting on their pain levels or activities for three day minimum. If I see things of concern, I will add more implementations or parameters on when to call the LN. The LN's are the only ones that can D/C alert charting for post hospital or post procedure...so we check to see if everything is well, and guage the situation before taking them off alert charting.

Seems to be a safe way to go, and does prove that the patient is being monitored and taken care of if things with medicare don't go smoothly.

NurseKatie08, MSN · Feb 5, 2009

CapeCodMermaid said:
We in Massachusetts MUST complete a monthly nursing summary on ALL residents regardless of their payment source.
And...we just had a corporate audit of 30 of our Medicare charts - say what you want, but you MUST have proper documentation to prove a skill, including a daily medicare note by a licensed nurse. Signing your initials to a med sheet after a Gtube feeding certainly wouldn't suffice for skilled documentation.

I'm also in MA, and this sounds the same for my facility. On our TCU, all patients need to have daily Medicare notes. They are divided between day & evening shift, as the night nurse has to do chart checks. I think the simplest way to explain them, is the way it was explained to me during orientation---you need to prove why that patient needs to be in the facility. I'm just 5 months in as a TCU/rehab nurse, and was asked to have another new grad shadow me, because admin likes my documentation so much. It does get repetitive, but it is a necessary evil.

We don't have monthly nursing summaries on the TCU (since they come and go so quickly) but the LTC floors definitely do.

barefootlady, ADN, RN · Feb 7, 2009

HELP!!!

Due to the bad weather, call ins, and lack of staff anyway, there have been 3 shifts I worked recently I did not chart one word!!!!! I could not, I had 31 patients to give meds and treatments. Who had time to chart???? Any suggestions would help.

CapeCodMermaid, RN · Feb 8, 2009

Could you go back and do late entries? Or really, if it's only 3 days and the rest of the documentation is good, you're probably okay. If your facility doesn't have a history of audits then you're okay.