HELP~ Medicare Charting on LTC Facility

I just passed NCLEX last week, and I finally found a job that pays really well for a new LPN without any prior experiences. However, after being on training for 2 days, I am kind of overwhelmed, yesterday my preceptor and I admitted 2 residents, and discharged one. We passed medications, hang ABT IVs, Tube Feeding, etc., call the pharmacy, doctor, kitchen, etc etc., fill out a lot of paperworks, and we had to do a lot of charting for the medicare residents. Seriously, I was really burned out! I am still having a hard time with medicare charting and I wish to hear from anybody their opinions and input on how to best chart on medicare patients that will save me time. Also, if anybody wants to share if they have a format that they use for this, esp. those who currently work in LTC facility.

Thank you very much!

I know the feeling of being overwhelmed in a LTC. I am a new grad and I have been at my current LTC facility a little under 3 months. At our facility, they have a cheat sheet in the nursing section that tells us their problem and areas to focus on. For example if the person is in for a hip fracture, one of my notes may look like this"

2000 Pt. is alert and oriented x3. Resting quietly this shift. V/S 120/70, 98.9,76,18. Asked for PRN pain meds. x1. Rated pain a 5. PT came to assist with positioning and transfers.Requested that 2 person assistance be used with transfers and bed mobility. Consumed 75% of dinner and drank 560cc of liquid. Incision site is intact, area is pink, no drainage or foul smell. Will continue to montior.KSP,LPN

Hope this helps

In my notes I alway include:

Vitals

Mental status

Facial Affect

PT,OT,ST visits

Meal consumption

CNA assistance

Lung sounds(respiratory related)

Signs of infection

Circulation check

Signs of Aspiration

Pain rating

These are just a few. It really depends on why they are there. Ask if they have a Medicare cheat sheet. Good Luck. It will get better.

okie dokie here we go...

• pt/ot/st and why ( mobility, strengthening ...)

• orientation

• reorientation to what and how often ( i am a dementia nurse so bear with me)

• is this person able to voice needs or are the needs anticipated by staff
  
• is this person cont or incont
  
• how often are we providing peri care - exp incont of b&b peri care provided every 2 hr and prn
  
• s/s of urinary infection or evidence of diarrhea
  
• physical mobility- how does the person get around (ambulation ,w/c or walker)
  
• does the person require assist example- x1 for standing or transfers
  
• how does the person complete adl's - x1 or x2
  
• eating - does the person feed themselves - are they having any coughing or choking
  
• any behavior issues
  
• any new skin breakdown
  
• lungs sounds , bowel sounds, abd distention, extremity pulses. anything else that you feel needs to be looked at.
  
• patient was admitted for something whether it be copd or chf make sure you chart on that system and how it is functioning.
  
• the medicare fbi likes it when you educate the patient on something each day. we have been flagged for this before. example: educated patient on am medications purpose and desired effects.
  
• pain if any- need level of pain then make sure if they are having pain you document that you gave them a prn (after you gave it of course) and also document if they are under routine pain medication. because the frequency of break through pain will determine if the routine pain meds need to be readjusted.
  
• after that sign your name and be done...of course i probably left out some goodies will re-post if i remember...

Thank you everyone for sharing your experiences and knowledge in the question. I really appreciate your tips especially on time management.

Will continue to montior.KSP,LPN

I was always told to not chart what you will do in the future, because you are charting what has happened, not what you believe will happen. I was also told to not chart that you are "monitoring" something unless you have an actual monitoring system in place (I/O sheets, telemetry, etc). Otherwise, you are "observing", not monitoring. It sounds stupid to me to have to differentiate between two words that essentially mean the same thing, but that's what I've heard from 2 CMS inspectors as well as a legal nurse consultant that worked for the corporate office of the LTC I used to work at.

As far as help on Medicare charting, our corporate office had customized cheat sheets covering various body systems and disease processes, with check marks next to the things that needed to be charted on. This helped to take a LOT of guesswork out of it.

It very simple once you get used to it(the medicare charting I mean, not the job). It is just full vitals and head to toe assessment(of which I'm sure you did a hundred of in clinicals). Then you need to know the reason that the patient is being skilled. Did they break a hip? GI bleed? That should be passed on in report, but if it is not be sure to ask. If the previous nurse does not know, you can probably find out in the transfer orders or care plan(if they have been there a little while). Then chart specifically to that problem in addition to the head to toe. Good Luck

I was always told to not chart what you will do in the future, because you are charting what has happened, not what you believe will happen. I was also told to not chart that you are "monitoring" something unless you have an actual monitoring system in place (I/O sheets, telemetry, etc). Otherwise, you are "observing", not monitoring. It sounds stupid to me to have to differentiate between two words that essentially mean the same thing, but that's what I've heard from 2 CMS inspectors as well as a legal nurse consultant that worked for the corporate office of the LTC I used to work at.

As far as help on Medicare charting, our corporate office had customized cheat sheets covering various body systems and disease processes, with check marks next to the things that needed to be charted on. This helped to take a LOT of guesswork out of it.

My facility will not allow those, because they think that people will get lazy and just check what they checked yesterday. We have to write out everything.

My facility will not allow those, because they think that people will get lazy and just check what they checked yesterday. We have to write out everything.