I am new to this site and I have some few questions regarding the medicare charting guidelines. Does anyone know where I can get a copy of this? I just started a new position at LTC and I am responsible for charting on all Medicare residents. Can anyone tell me if there is a book I can get or a website that can help me? I would really appreciate it so very much. Thanks a lot.
There is no specific guideline. The purpose of documentation is to prove to your Fiscal Intermediary that a skilled need is present and the care provided. During a Medicare audit, they will be scrutinizing the medical record for these services you have claimed for.
1. If you have a resident who comes back from the hospital for Pneumonia, you will need a daily note to prove that you are actually observing a resident from adverse effects. The reason for a daily note is that you cannot document elsewhere that you provided this skilled care. One daily note would suffice.
2. A resident who is covered for a new gastrostomy feeding does not necessarily require a daily nurses note unless you need to document any untoward reactions from use of the device or formula. Why? You already have an MD order for the GT feeding. You are recording the daily intake; and you are signing the MAR when a feeding has been provided.
3. A resident who is on Physical therapy will have an MD order, a therapist evaluation, and an attendance record.
Some will disagree strongly about daily charting. All I can say is that it is simply repetitive and unnecessary. It is an old habit. This is one reason why MDS/PPS was implemented.
Back in 1996, my facility joined the New York City pilot study for PPS. The primary concern raised by the participants was the voluminous and redundant documentation that Medicare required. MDS/PPS will eliminate the dilemma.
We have a Fiscal Intermediary auditor who comes annually at our facility since 1998. Not once were we ever questioned about the inadequacy of our method of documentation.
Common sense... if you claimed for a skilled need, simply show evidence that the care is provided.
Last edit by Talino on Jun 7, '03
Dec 8, '04
i believe i did not see any content in that message but a wink!
Last edit by dieseldycke on Dec 8, '04