I am new to LTC w/30 patients. Three of my residents are skilled, and I was told that skilled care requires documentation every shift.. I'm really not sure what to put in a skilled note exactly...I believe its different than a general assessment? Any advice? Thanks in advance!

Specializes in LTC, Geriatrics, MDS.

In my state is once a day with like rehab therapy like PT/OT/ST, q-shift with IV or general nursing. Ill just give an example of what we expect in our notes.

Resident cont skilled for PT/OT. A&Ox3. Speech clear and appropriate. Able to voice demands and follow directions. Mucous Membranes moist/pink/intact. Lung sounds clear t/o all fields with no c/o cough or SOB. Resp even and non-labored. Heart rate regular. Abd soft non-tender non-distended with bowel sounds positive x4 quads. Denies n/v or loose stools. Continent of bowel and bladder. Pedal pulses palpable. No edema observed bil. Able to feed self with tray set up. Min assist with ADLs and transfers. Denies c/o pain or discomfort. Will continue to monitor.

Also if its for a IV you would chart what they are getting (ABT=reaction? effect?) and the IV site. Just double check with your facility's policy.

1
Up Vote Up Vote ×

THIS IS WONDERFUL!!!!!! THANKS SO MUCH

1
Up Vote Up Vote ×
Specializes in geriatrics,wound care,hospice.

Our MDS coordinator laminated heavy copies of these and PERSONALLY handed them out to all nurses in our facility to guide our charting. After years of SOAP,narrative,checklist and general meandering around trying to capture the past 8 hrs.of this person's life in our SNF,these guidelines really help narrow the (reimbursable) focus on the nursing care delivered. PT/OT/ST chart their own notes,so no repititon in NN.Also emphasis on the lowest level of skills demonstrated by pt.and ANY performance of nursing assistance provided.

1
Up Vote Up Vote ×

Hold onto your nurse cap, I'm about to blow your mind!: 'Skilled charting' doesn't really exist. The need for 'daily' documentation does exist for patients covered by Medicare, or certain HMOs, etc. that covers their 'reason for admission' (diagnosis), and physicial need for 'rehabilitation', which is very expensive. You may be suprised to hear that MOST 'skilled nursing patients' would never be in a SNF, if it were not for the rehab department? If not for almost daily rehab, those people would be sent home with home health care, and NO rehab. It's much cheaper to provide rehab in a SNF. Also, no actual 'nurses notes' are even required. If a COPD patient comes into the SNF with pneumonia, and resulting weakness, inability to take care of his ADL? Flowsheets, MARs, TARS, ADL documents, and rehab progress notes (which is what case managers REALLY pore over) are what the pay source will be looking for, to substantiate or to disclaim the need for the placement (AKA payment) in the SNF. What nurses notes do, more often than not , is to contradict the efforts of the rehab department to paint a clear, concise need of rehab required for the patient to return to the prior, lower level of care.

Sorry to burst your bubble- but the majority of 'skilled nurses notes' in a SNF are wasted effort, and busywork. Why do them, than? Many managers feel that if they require daily notes, there will at least be 'something' for the case managers to read- even if the notes are contradictory to the reason for the 'skilled admission'.

1
Up Vote Up Vote ×
Chris81 said:
Our MDS coordinator laminated heavy copies of these and PERSONALLY handed them out to all nurses in our facility to guide our charting. After years of SOAP,narrative,checklist and general meandering around trying to capture the past 8 hrs.of this person's life in our SNF,these guidelines really help narrow the (reimbursable) focus on the nursing care delivered. PT/OT/ST chart their own notes,so no repititon in NN.Also emphasis on the lowest level of skills demonstrated by pt.and ANY performance of nursing assistance provided.

I've seen 'many' instances of denied claims for skilled care, based soley upon having 'skilled charting' guidelines posted in the chart, as a sort fraudulent charting platform that was based solely on the reimbursement focus, rather than on the condition or needs of the patient. In fact- one of the first things a medical record person usually does upon discharge is to REMOVE those 'guidelines' from the chart.

Some companies do not allow them, some do, some require them, in fact. The net result, however- is a lot of more wasted time, that reduces LTC staff to paperwork mules, and having no time to perform compassionate, competent care for their charges.

1
Up Vote Up Vote ×
Chris81 said:
Our MDS coordinator laminated heavy copies of these and PERSONALLY handed them out to all nurses in our facility to guide our charting. After years of SOAP,narrative,checklist and general meandering around trying to capture the past 8 hrs.of this person's life in our SNF,these guidelines really help narrow the (reimbursable) focus on the nursing care delivered. PT/OT/ST chart their own notes,so no repititon in NN.Also emphasis on the lowest level of skills demonstrated by pt.and ANY performance of nursing assistance provided.

What case manager$ look for in fact, is whether nursing documentation jives with rehab notes, not so much the oher way around. It is not a matter of repetition (and case managers aren't EXPECTING repetition- they get paid to get peole OUT!)- it's a matter of agreement. If a nurse charts, for example, that a recent hip fx. 'got self OOB, walked down the hall to the TV room with no device, watched TV, then walked back to her room, with no device, and then put herself to bed', and yet PT claims that patient is a 'mod/max assist of one to transfer' and requires an assitive device? Be sure to leave some time open tomorrow for a discharge- because that patient is going home with home health. REAL quick.

Again: Skilled 'nursing notes' in a SNF? Whatever.

-Been there, Done THAT.

1
Up Vote Up Vote ×
mary1839 said:
THIS IS WONDERFUL!!!!!! THANKS SO MUCH

One more note, on 'skilled nurses notes':

Used to be that the rehab professionals worked FOR the SNF, like nurses do. When the PPS came about, rehab people became employees of rehab companies that provide services to SNFs- because without those services, SNFs would not be able to admit 'skilled patients'. (Again- skilled patients in nursing homes are there for rehab, not nursing, in most cases, sorry!).

This creates a sort of barrier- the SNF doesn't like to pay the rehab companies the big $ they require, and also- the therapists are sort of treated as outsiders in the SNF, because they don't 'work FOR the SNF'. There's a certain weird relationship now. But if you talk to any PT, OT, or ST (or rehab aide) , you'll find them all very intelligent, caring, and willing to help in any way they can with any patient- but their hands are also tied by 'billable hours' constraints, and 'productivity' mandates.

1
Up Vote Up Vote ×
Specializes in NICU, Peds, Med-Surg.

Thank you, CapeCod Mermaid----I'm going to print out that PDF---very helpful! :)

1
Up Vote Up Vote ×

We recently stopped having to chart transfer and adl items. MDS checks transfer status and keeps it updated in their computer. They said what we did was a waste of time and not helpful to guidlines. Half the people weren't recording things right. Someone would write they were independent, while the next person would write one person transfer. Along with the chart change, everyone also had to attend an education class on what each type of assist actually truly meant.

1
Up Vote Up Vote ×
Specializes in Gerontology, Med surg, Home Health.

I've been involved in more than a few audits. Sometimes what the nurses documented was the difference between a claim being denied and a claim being paid. Obviously we all have different opinions. Follow your facility's policy for documenting.

1
Up Vote Up Vote ×

Beside the omniform where else can I go to do my skilled nursing progress notes?

1
Up Vote Up Vote ×

I live in NC and in my facility, Medicare requires that we chart on all patients every day every shift!! its ridiculous.

1
Up Vote Up Vote ×
+ Add a Comment