Skilled Notes

  1. hi, 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.. t Im really not sure what to put in a skilled note exactly...I believe its different than a general assessment? any advice? thanks in advance!
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  2. 22 Comments

  3. by   BrandonLPN
    Just make sure it relates to their dx. If they have a UTI chart that they are being toileted, fluids are being pushed, their LOC. If they are post op chart on the condition of the dressing(s), bowel sounds, pain level, vitals. Don't chart some generic, long winded "head to toe" assessment. It looks amateurish. Keep it brief but relevant to what they have going on. If they are simply LTC residents chart their LOC, whether or not they're eating, how they're sleeping (or not sleeping), if they go to activities, stuff like that.
  4. by   serenidad2004
    Quote from Isitpossible
    hi, 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.. t Im really not sure what to put in a skilled note exactly...I believe its different than a general assessment? any advice? thanks in advance!
    I worked 9yrs between skilled/LTC when we did our skilled charting we charted to the dx as previously stated. We also charted how they transfered/ambulated toileted incontinence etc. You need to chart to prove skilled nursing services/monitoring are needed and also to show progress. Ex: on admit "pt up with assist of 1 pivot transfer to wc propeled to meal per staff" then say day 5 "pt up with one ambulates with CGA et wheeled walker to meal" and of course vitals q shift et prn and I & Os.
    Hope that helps
  5. by   amoLucia
    You might want to check with your Staff Development nurse or or MDS nurse for information as they probably have loads of samples to help you chart effectively. As stated by others, charting is diagnosis-driven and it correlates closely with reimbursement purposes. It should explain to the reader what it is that the nsg staff is doing for the pt that requires a skilled approach that couldn't be done at home. Does that make sense? What are we doing that is special for this pt? What's the diagnosis --- what are we doing and how is the pt progressing (or not progressing)?

    Usual diagnoses reflect rehab needs post surgery/post stroke, cardiac and/or respiratory dysfunction, advanced wounds, new gt tubes, fractures, etc. Our nsg interventions include our assist with ADLs, IV therapy, wound care, oxygen/neb therapy, TEACHING, etc and pt response.

    You might also find another nurse who charts well and you'll be able to follow that charting as samples.

    Hope that helps.
  6. by   CapeCodMermaid
    Do a search on allnurses for Daily skilled documentaion guidelines. You will find at least one cheat sheet on the subject.
    I believe after the first 72 hours, Medicare only requires a note every 24 hours. We split ours up between days and evenings.
  7. by   CapeCodMermaid
  8. by   vampymegs
    this link was great ... thank you so much for posting!
  9. by   CapeCodMermaid
    No problem. We all help each other out here.
  10. by   Isitpossible
    CapeCod!!! thank you soo much... sorry the late "thank you"...!!!!
  11. by   Spring_Peeper
    Thank you for that great link, CapeCodMermaid. I made a copy to keep on my clipboard.
  12. by   tnguy31
    Thank you Capecod, this is so helpful. exactly what im looking for.
  13. by   CapeCodMermaid
    Glad to be able to help out.
  14. by   feelsafewithanurse
    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.

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