Medicare chart requirements

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Hello, I'm new here but have been doind MDS full time for 3 years. I am trying to find out if there are any requirements as far as how much of a SNF chart can be thinned? I know i need to keep any supporting documentation regarding my most recent MDS but is there anything else i need to keep? Also how long do I need to keep acute care copies on chart? Any advice would be greatly appreciated.:D:typing

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Specializes in LTC, Hospice, Case Management.

I am used to seeing 3moths worth of documentaion on the charts, but not sure if that is an offical rule. As far as acute careplans, you should be able to "thin" that out as soon as the issue is resolved. Obviously you want to put that in overflow and not throw it away!

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Specializes in ER CCU MICU SICU LTC/SNF.

Other than the more stringent requirements for MDS purposes, record keeping is left at the facility's discretion. Having an overflow chart in the unit will surely keep that active chart light. Do whatever works for your resident population and staff.

Thinning Records Excellent info, scroll down for recommendations.

AHIMA

...can't resist :dncgbby:

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Specializes in mds coordinator, DSD, Vent Nurse, Rehab.

Talino,

That was a great lead for chart thinning informaiton. It has a nice chart that you can print out and use.

Thank you. I have been looking for this on the back burner so to speak.

Callinurse

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Specializes in LTC QI MDS.

Does anyone know when NY will be required to convert to an electroni medical record?

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