LTC Documentation Newbie

The guidelines for documentation in LTC are the same as in the hospital. If you didn't document it, it didn't happen. Late entries: put the date it is, then "late entry for 1/24/08 for example and then write your note. When charting on Medicare or Managed care patients, make sure your note includes specifics about the patient's diagnosis. If they were admitted status post hip fracture, for example, your note should include level of pain, anticoagulants, assessment of the incision site, how they are doing with therapy. In other words, document on the reason Medicare is paying for them to be there. "Pleasant, ate well, bowel sounds in all 4 quads"...I see that note more often than not. Medicare doesn't give a care if they are pleasant.

CapeCodMermaid is right. Your documentation needs to serve as evidence of justification for the level of care being provided, which is going to be more important for skilled units. Charting also needs to reflect the care plan. There are several books out there on LTC documentation, but the only one that is affordable is by Marilyn Smith-Stoner, Long Term Care Documentation and Reimbursement. You should be able to get a copy from Amazon.com for around $5. The ISBN number for that book is 1569300798.

Thanks so much for the information. In clinicals it was all document by exception on computers. Most checks and x's. Reality is now using the trusty black pen, first to note to remember that you have to document it, and then documenting it. This I was never taught. I think when a BS is low, I need to document it in four places, what I did because of it, how the patient was feeling, and how the patient was afterwards. CYA, document, document, and when the time is left, take care of the patient....glad I love this job!

Just found this terrific resource a few minutes ago -- apparently AHIMA has created a documentation and medical records manual for long term care and made the thing freely available on their website at http://www.ahima.org/infocenter/guidelines/ltcs/.

When documenting a late entry, always note somewhere the reason your entry is late. Example: Jan 26th @ 1422: late entry for Jan 26th @ 0935 (activity on unit)

...or whatever the reason. If that documentation is ever called into court and you're on the stand, you can be asked why you documentation was late, essentially calling your practice into question. Your health region, governing body, etc. should have standards on documentation for you to follow. I'd go with what the previous posters have written, too.

LOL... that book now is $99