Medicare Charting guidelines

  1. 0
    Hi, Everyone!

    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.
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  5. 3
    Welcome!

    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
  6. 0
    Good post talino. I agree 100%!
  7. 0
    Where I work, the Medicare residents must be charted on q shift for their first 72 hours and then daily after that, regardless of where else the information may be found
  8. 0
    Quote from Talino
    Welcome!

    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.
    talino...

    i am enjoying a lot, and i would say have learned a lot from every messages you've posted. can i ask you something, is there a certain law or regulation underwhich nurses in LTC are required to accomplish weekly summary report, im not very knowledgeable when it comes to governing laws, state or federal that dictates about weekly summaries. pls reply back, if possible pls email it to me at dieseldycke@yahoo.com

    thanks.
  9. 0
    message sent :wink2:
  10. 0
    i believe i did not see any content in that message but a wink!
    Last edit by dieseldycke on Dec 8, '04
  11. 0
    Quote from dieseldycke
    i believe i did not see any content in that message but a wink!
    ...must be Yahoo's mail spam protection feature. Anyhow, here's the full text-

    NO, there is no regulation requiring SNFs to have routine nursing summaries.

    For stable residents, the quarterly MDS and care plan review is more than sufficient to depict a resident's state of being. Any changes in the interim can be a address in a nurses progress notes.

    However, I wouldn't recommend disputing your facility's standard of practice. This is a fixation that has been passed on from one Nursing Administrator to another which may require a "federal mandate" to obliterate the old habit.

    Here's also a link to this same issue....
    http://allnurses.com/forums/showthre...9&page=2&pp=10
  12. 0
    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.
  13. 0
    Quote from CapeCodMermaid
    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.
    The Medicare "daily nursing notes" you mentioned may be imposed upon you by your Fiscal Intermediary, not by CMS. But I would be surprised if the requirement specifically says that a "nurse" has to make such documentation.

    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.

    I do not dispute each facility's practice. Do what worked best for you.


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