Documentation-- Who trains new nurses?

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Specializes in LTC-Geriatric-PPS-MDS.

In your facilities--- Who trains new nurses how to document for Med A and Medicaid? Or just overall documentation? Our facility is leaving it up to the floor nurses and myself (PPS coordinator) and MDS coordinator...

Problem is--floor nurses do not do a great job... and MDS coordinator and myself barely have time to breathe let alone train new nurses...

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I would think it would be part of the orientation process, since revenue heavily relies on documentation. If it isn't, maybe the PPS/MDS person ought to give routine inservices, despite the lack of time- it'll pay for itself when the assessments are due. Fact is in LTC everyone is pulled in so many different directions, but a lack of proper and accurate and timely documentaion will adversely affect your MDS job, possibly more than anyone else's job, directly.

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Specializes in ICU, CM, Geriatrics, Management.

Very quick review plus handouts at orientation classroom session.

No real quality time devoted to this.

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In your facilities--- Who trains new nurses how to document for Med A and Medicaid? Or just overall documentation? Our facility is leaving it up to the floor nurses and myself (PPS coordinator) and MDS coordinator... Problem is--floor nurses do not do a great job... and MDS coordinator and myself barely have time to breathe let alone train new nurses...

I started my first LTC job in October and NO ONE taught me how to properly chart on Medicare. And 4 months later I am still no sure I'm doing it right. I've asked for help and I just get told "just xhart everything you can think of plus a full set of vitals". So that's pretty much what I do, while looking at other nurses notes to see how they do it. If management wants to get on my case about it, I can make a great case for their totally inadequate training.

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I started in my nursing career in ltc. My facility has charting ques sheet for mcr charting. Each mcr patient has one issued by the mds...it states their admit dx and comorbidities. It has a list of common dx's and the what aspects need to be included in charting. The mds nurse highlights what pertains to that specific pt. It really helped me as a new nurse. Now I have been at it 2.5 years (sill a baby nurse)...and what is expected is burned in my brain.

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Specializes in Gerontology, Med surg, Home Health.

We give all the nurses a basic "what to chart" based on the diagnosis.

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