Charting

For any Med A patients you need to chart on the reason they are there for skilled care. For example, if they are there with a total hip replacement you would chart on the incision, the level of pain, their working with rehab, anticoagulation and the like. Don't bother with 'pleasant, ate well.' No one cares. If you search through the Geriatric Nurses posts you'll find a medicare charting guideline.

For the non Med A patients...chart by exception.

I would ask for your facility policy as to what the charting requirements are. CapeCod is right MedA is one of the most important in that you have to document the reason for the stay as she mentioned. Most facilities spell out their charting requirements and it should have been something that was given to you during your orientation.

This is what I've used in 3 buildings (so far). I hope it helps.

DAILY SKILLED DOCUMENTATION GUIDELINE.pdf

I love that guideline from capecod. I really try to chart on everyone, including any behaviors. I never really liked the charting by exception concept, it seems in LTC almost everyone has something to be monitored or addressed. The medicare does require a little more extensive charting, and I try to rotate the thoroughness of the 'more stable' residents, understanding that time isn't abundant. It feels that in LTC more focus is on getting through the med passes vs assessments and critical thinking.

This is what I've used in 3 buildings (so far). I hope it helps.

Thank you CapeCod. this is really a big help. i'm still a little weak when it comes to documentation but i'm getting better. this will really help. thanks again.