Medicare/Medicaide Documentation help

[emt2rn82]

Hi I'm new to LTC and am wondering if anyone has any references for documentation help, mostly involving Medicare/Medicaide charting. So far I will only have 1 day on Desk orientation and am fearful of not documenting everything that needs to be documented. I received a small book on all the paperwork for the agency but nothing on the makings of a nursing progress note. I work in Cardiac Surgical ICU presently and know how to chart on the critically ill, but am a little wheary on charting on the "healthy" in the nursing home. Any advise would be greatly appreciated. Thanks in advance

[CapeCodMermaid, RN]

For Medicare charting: think of why the resident is there under a skilled benefit. Fractured hip with ORIF: pain,the incision site,anticoagulant,how they are doing with PT. Pneumonia:respiratory assessment,antibiotics,use of O2. You can skip the ever present 'pleasant,ate well' because frankly Medicare doesn't care if they are pleasant.

As for charting on 'healthy patients'...don't. You have to do a summary on every Medicaid resident once a month but unless your facility has other policies, you don't have to chart on anything but something out of the ordinary. There are all sorts of books on how to chart. We put a cheat sheet in the front of every Medicare chart with the reasons for skilling circled. If you want to send me an IM with your email address I'd be glad to send you a copy.

[athomemom56]

I'd like a copy of the cheat sheet. I tried to email you privately so I could give you my email addy. Can you send me yours.

Barbra

[Joni Suemnicht]

I would love a copy of your cheat sheet. I am trying to help the LPNs with more complete charting especially for the Med A covered residents.

[email protected]

[CapeCodMermaid, RN]

Look back in the MDS Coordinator section under Looking for Medicare Charting Templates. Go to post #22 or 23 and the templates are there.

Good luck

[CapeCodMermaid, RN]

Never mind.....see below

DAILY SKILLED DOCUMENTATION GUIDELINE.pdf