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.
  2. Visit  dimpsogre profile page

    About dimpsogre

    dimpsogre has '4' year(s) of experience. From 'I guess I live at my house :)'; 41 Years Old; Joined Jun '03; Posts: 66; Likes: 2.

    21 Comments so far...

  3. Visit  Talino profile page
    4
    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
    Shayon, favraeRN, mommiedearest, and 1 other like this.
  4. Visit  FutureRNMichael profile page
    0
    Good post talino. I agree 100%!
  5. Visit  CapeCodMermaid profile page
    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
  6. Visit  dieseldycke profile page
    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.
  7. Visit  Talino profile page
    0
    message sent :wink2:
  8. Visit  dieseldycke profile page
    0
    i believe i did not see any content in that message but a wink!
    Last edit by dieseldycke on Dec 8, '04
  9. Visit  Talino profile page
    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
  10. Visit  CapeCodMermaid profile page
    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.
  11. Visit  Talino profile page
    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.
  12. Visit  Antikigirl profile page
    0
    We will chart every 90 days if a resident is stable with no changes in condition. If a condition is a fall, cold s/sx, UTI..things of this nature that will pass but need to be monitored, a nurse will put the patient on 'alert charting' and designate the type of charting needed. That has really helped us cut down the unneeded shift charting on some issues like skin tears or bruises (why chart q shift on a condition of these? We also monitor these issues on the MAR, so it is documented daily anyway).

    We also do random chart audits every month..actually that is what I did! We would have a random list of 12 patients per month and I would go over their last month and make sure I felt charting was sufficient. Making it random helps, but last month...the random only showed 2 people that had a change in condition, so the others were rather borring..LOL! But I did find some slack in charting on weights or I/O or even bowel monitoring..and since a patient is charged for this...I caught it and got things back on track!

    If a person is on hospice it is q-shift for communication reasons to hospice nurses. If they came back from the hospital, depending on condition it is policy to chart q shift for 3 days..but we nurses can extend it if we wish. Falls are 3 days too, same guidelines about lengthening it (ie pain issues or increased confusion post fall...).

    The nicest thing we started doing is if things are very important to chart, caregivers must sign the MAR stating that they charted, or simply that they checked on that particular issue (ie skin issues). They have to fill out a shift summary and a 24 hour communication report as well...so if I don't sometimes see it in the chart..it will be in there, and I have them do a late entry if needed in the chart. That has been sooooo helpful and cut down unneeded charting quite a bit (or charting the same things in three or five different areas!).

    IT has been helpful that the nurses have say over charting, and we have some guidelines for when we go "shoot...ummmmm I don't know" LOL! It really caters to need of individuals specific to their changes or conditions as they progress, and has improved over the year we have tried this! We have also gotten kudos for documentation of skin issues via the MAR (we also have weekly checks by LN on larger than 2cm tears or over 3 cm bruises till resolved on a separate sheet of paper in the MAR, and charting...so it is very followed through, especially since medicare kept on declining to pay for dressing supplies!).
  13. Visit  blessed02 profile page
    0
    :uhoh21: Thank you all for the info-this is really scary for me.I work in an assisted living and most nurses do not get time to chart because of work overload-we have one nurse on duty in a 7 floor facility and you have to chart on people who have something going on-but at the end of the shift you have taken no break and you're not supposed to stay more than half an hour over-i stay anyways and chart and i'm waiting for the day i'll be fired for staying over-problem is other nurses just go home and do not chart.:angryfire
  14. Visit  dieseldycke profile page
    0
    Quote from Talino
    ...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
    youre good, how long have you been in this business? i like every comments you make, and you always add it up with a good sense of humor, if you are a DON in a certain facility, oh ill be applying to be your staff, and get a good training from you. are you filipino by the ways???


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