Charting Frequency Long Term Care Medicaid

I make our nurses chart each shift when they are on skilled.

The LTC residents have to be charted on each shift if there has been an incident, abx usage, new orders,

When a LTC medicaid resident is in an assessment period I place a white sticker with the ARD date on the spine of their chart. I usually do all of the ones for the next month in the last week of the previous month. I expect a detailed note within the week before, including ADLs, B/B, any behaviors, moods, etc.

Of course, this only happens about half the time, but you work with what ya got, right?

we have a monthly charting schedule for our facility plus a weekly assessment that included the Section B documentation. I did an inservice on doing a monthly summary in the nurses notes which included what abt's they were on, what are they doing in restorative, b/b, transfer status, how they made needs know, how they eat, etc..

Monthly summary-like a mini-physical. For the annual MDS I push for another "Admission Assessment" from nursing, going over them from head to toe, as if they were a new admit.

anyone got a good monthly summary form ours stinks- they are making the nurses do weekly summarys but it is just check off list and they dont do a summary of what happened with the resident all month so hard to capture stuff.

Most summaries I've seen are the check off kind with spaces for comments. I don't know too many people who actually write comments. I have a summary if you want to take a look at it....IM me with your email and I'll send it to you.

Monthly summary-like a mini-physical. For the annual MDS I push for another "Admission Assessment" from nursing, going over them from head to toe, as if they were a new admit.

Sorry, and maybe I'm being overly sensitive, but you said you push for another from nursing.....aren't YOU nursing?

Well, I am a nurse, an MDS coordinator, but unfortunately, with 230 residents, I HAVE to rely on the floor nursing staff to do the physical assessments. Sure, I could do them, but with anywhere from 15-38 MDS assessment due weekly between Medicare PPS and the quarterly, annual, sig change...I have a hard enough time getting what I have to get done, without adding the physical assessments. I am considered Nursing administration, do oncall, and weekend manager responsibilities. I am salaried and wish I had 8 arms sometimes!!!