Vital signs

[CapeCodMermaid, RN]

Is it necessary to do vital signs every shift every day of someone on Med A. We're having a discussion about it at my facility. I say once a day after the 1st 72 hours, but I've worked at places where it was 3x a day for the first 72 then 2 x a day for the rest up till day 14 then daily after that.

Does anyone know the regs?

[DixieRedHead, ASN, RN]

I don't know the regs. In my facility we do VS q shift as long as they are on Med A.

[CapeCodMermaid, RN]

Yeah..but I really hate to wake people up if their vitals signs are stable. Thanks.

[VivaLasViejas, ASN, RN]

When I worked LTC, vitals, I&O, and full assessments were done Q shift X 7 days, then it was VS and full assessment once daily until discharged from SNF. We had to chart on these residents every shift with emphasis on the reason(s) they were skilled, which wasn't easy when I worked night shift and never saw them working with therapies or performing ADLs such as dressing and feeding themselves. It's pretty intense when you have 15-20 Medicare pts, plus several ICFers on alert charting for new meds, illness or whatever reason. I don't miss those days one bit!

[Talino]

there is no specific guideline. the purpose of documentation is to prove to the medicare contractor that a skilled need is present and a skilled service provided.

although daily documentation is crucial to support the need for skilled coverage, does collecting vs support the condition for which a skilled service the resident receives? for most skilled nursing services, maybe yes. but for skilled rehab with no underlying medical conditions, vs collection is but a facility routine.

[CapeCodMermaid, RN]

Thank you.