HELP~ Medicare Charting on LTC Facility

NC Girl BSN · Nov 30, 2007

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.

TheCommuter, BSN, RN · Nov 30, 2007

It seems as if you work on a skilled unit at a nursing home. Am I right?

I work on a fast-paced rehab unit at a nursing home. For medicare charting, I pick a few significant things that occurred with the patient, then I'll chart a paragraph on them. You can chart about IVs, antibiotics, PEG tubes, diabetic management, responses to PRN pain meds, responses to breathing treatments, skin condition, wound appearance, surgical incisions, dressing changes, patient behaviors, any injections given, oral care, baths, toileting, ADLs, ambulation, new orders, doctors' visits, and so on.

I'll also give you some time management tips that might keep you from getting overwhelmed. I work 16 hour shifts, from 6am to 10pm. Typically, I have about 15 patients to care for. At the beginning of the shift, I'll go through the MARs and TARs with a fine tooth comb and, as I go, I will jot down the things that must be done in my notebook. My notebook is how I organize the rest of the day, and I usually won't forget to do anything. Here is how Sunday's notebook page looked (names have been changed due to HIPAA):

11-25-2007

DIABETICS, FINGERSTICKS: Agnes (BID), Agatha (AC & HS), Bill (AC & HS), Wendy (AC & HS), Rex (BID), Jack (BID), Esther (AC & HS), Margie (0600, 1200, 1800, 2400)

NEBULIZERS: Margie, Esther, Bill, Jack, Jane

WOUND TREATMENTS: Jane, Bill, John, Jack, Lillian, Rose, Lucille

IV THERAPY: Wendy (Vancomycin), Laura (Flagyl), Rex (ProcAlamine)

COUMADINS: Agnes, Agatha, John, Lucille

INJECTIONS: Agnes (lovenox), Jane (arixtra), Rex (heparin), Bill (70/30 insulin), Esther (lantus), Mary (vitamin B12 shot)

ANTIBIOTICS: Wendy (wound), Laura (C-diff), Rex (pneumonia), Agatha (MRSA)

1200, 1300, 1400 meds: Margie, June, Rose, John, Jane, Jack

1600, 1700, 1800 meds: Rose, John, Rex, Lucille, Lillian, Laura

REMINDERS: assessments due on Agatha, Jill, and Louise; restock the cart; fill all holes in the MAR; follow up on Jane's recent fall, fax all labs to Dr. Smith before I leave, order a CBC on Rex...

txspadequeenRN, BSN, RN · Nov 30, 2007

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...

j3yang21 · Dec 1, 2007

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

Murse901, MSN, RN · Dec 1, 2007

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.

swimmom · Dec 5, 2007

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

swimmom · Dec 5, 2007

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.

caliotter3 · Dec 5, 2007

On at least two different occasions when I worked in LTC, I was given a handbook or a handout on medicare charting. However, I'm pretty certain that those have been lost through the years. The biggest thing that I remember about one of them, was the focus on the medical diagnoses of the patients and how they are addressed. They also had a list of words to avoid, words that look like the resident is getting routine care rather than skilled nursing care. You can't chart anything that looks like it is "status quo" every day and every week. That is about all I can pull off the top of my head. If I were to find one of these handbooks, which I don't expect that I can, I will do my best to come back to this thread and give some examples. Sorry I couldn't be of more help.

Murse901, MSN, RN · Dec 6, 2007

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.

I didn't mean a form with checkboxes that replaces charting. Just a checklist/guidelines for charting. Everything had to be handwritten or typed into the computer charting system.