skilled charting

Hi. There are innumerable "answers" to your query , and no specific regulatory guidance.

Although some facilities/consultants require/teach "q shift documentation". this approach frequently results in pointless and repetitive nursing documentation.

The patient must receive a daily** skilled (means provided by licensed staff) service--and documentation must reflect that the service is given. A professional will also evaluate and document the response to the service.

For "direct" services, such as therapy, tube feeding, ulcer care, IV therapy, etc.-- documentation of the service itself may be sufficient--combined with periodic documented evaluation of patient response.

For "indirect" services, such as monitoring for acute condition, pain management, instability, response to treatment, potential for instability, etc.--logs or flowsheets (noting observations pertinent to condition) can document objective information/data such as vital signs, pain, behavior, etc. Nursing documentation (daily at minimum) should reflect analysis--"put together" the collected information/data--

• What is the patient's response to treatment? Does the data show stability (a NO-NO word!!), a potential for instability (based on what?), improvement, decline, etc.?
• What do you or other professionals plan to do based on this analysis?

This is probably not as helpful as you would like it to be.
Q shift charting without focus is a waste of time. Notes written by licensed staff must demonstrate daily skilled care given by licensed staff. In some cases, "skilled" = documentation that a nurse has analyzed information, made an evaluation, and has planned future care (with other professionals) based on this evaluation...


**Daily=7 days/week--except rehab therapy can be 5 days/week


Best of luck!

Our facility makes us chart q shift on medicare, ABT, and behavior issues residents, and yes, a lot of it is very repetative

Roxann

Skilled Charting - At least daily to make evident to any Fiscal Intermediary why you are being paid to provide skilled services to the patient.

If they are skilled, but also had a change of condition, antibiotics, or other circumstances requiring even more observation and interventions, then you would address those at least qshift until the condition resolves (or has a different outcome - i.e. significant change in status reassessment MDS).