medicare charting and documentation

[hope3456, ASN, RN]

Just graduated RN school and landed a job in LTC night shift. I am really at odds with this facilities charting and documentation practices. I really don't know if I am 'covering my a$$' part of the time and can see how alot of things are being missed, but then some of the forms that we have to fill out seem so redundant, pointless and time consuming, for example, the pain management sheets (long story). When it comes time for the state inspection, I can forsee this place being 'hung out to dry.'

We do have a 24h report sheet and i am responsible for making it out and deciding who should be on it and who should be taken off. Also, theoretically, everyone on there should be charted on, but it is not happening. There is not time.

The problem is, I was never given any formal guidelines. I have asked other nurses, they don't seem to know that there are any, nor do they care. Everyone seems to have their own 'rules' and there is no consistency. The DON who hired me just quit on short notice, so this place doesn't really have any effective leadership.

So if anyone can give me 'the basics' on how the charting process should work, I would appreciate it, as well as any pointers to make it faster, while making sure you cover yourself.

Also, when a resident comes back from the hospital on medicare, how long are they on medicare and how long should you chart on them? I am sure that is a stupid question, but none of the other nurses I work with know, either.

Appreciate any info.....thanks!!

[CoffeeRTC, BSN, RN]

Okay...this is how we do it. 24 hr report is for any changes in resident condition. Each day we start with a blank sheet and write and residents/ problems as they occur. When I worked 11-7 I would put residents names down for a reminder, like if a lab was pending.

Chart on any thing you wrote on 24hr report. We also do vitals and chart q shift on residents with antibiotics. q shift for 3 days on all admits, readmits and incidents. As far as medicare charting...as your RNAC or MDS person who is on medicare and what are they being skilled for. At the very least they need q day charting until their skilling need is resolved or they are out of medicar days (100 days)

As far as what else to chart on 11-7 any residents having trouble sleeping, behavior problems, trying to get oob, etc also any family issues any doc calls and new orders along with all the changes in conditions.

In my facility medicare charting is split between days and evenings...days gets the residents skilled for therapy..evenings mostly the wound care and other skillers.

[Bird2]

Okay...this is how we do it. 24 hr report is for any changes in resident condition. Each day we start with a blank sheet and write and residents/ problems as they occur. When I worked 11-7 I would put residents names down for a reminder, like if a lab was pending.

Chart on any thing you wrote on 24hr report. We also do vitals and chart q shift on residents with antibiotics. q shift for 3 days on all admits, readmits and incidents. As far as medicare charting...as your RNAC or MDS person who is on medicare and what are they being skilled for. At the very least they need q day charting until their skilling need is resolved or they are out of medicar days (100 days)

As far as what else to chart on 11-7 any residents having trouble sleeping, behavior problems, trying to get oob, etc also any family issues any doc calls and new orders along with all the changes in conditions.

In my facility medicare charting is split between days and evenings...days gets the residents skilled for therapy..evenings mostly the wound care and other skillers.

Antibiotics - vitals and assessment until antibiotic is completed.

Incidents - 72 hours -then if they have a bruise, skin tear etc continue to chart at least daily until resolved.

Admits - 72 hours

Medicare - you need to know what they are being skilled for. For example if they had a hip fx your charting should really concentrate on the therapy they are doing, how they tolerate the therapy, pain, are they compliant with weight bearing precautions, incision line etc.

Most LTC have a print out of each Medicare Dx and guidelines on the charting that is needed. Duration for each Med A resident differs. They start off with 100 days of coverage but if they meet their goals or won't particpate they have to be taken off Med A. Your MDS person should know all the details.

We keep a log that lists every resident that needs charting. What the problem is and each nurse initials the area when the charting is completed.

Example Mabel - Levaquin x 7 days Dx UTI

The monthly summaries that are completed on all of the residents then cover the residents that did not require any charting during the month.

Always include vitals in the charting listed above and of course notify family and MD's of any changes in condition.

[MsLpn02]

Here is an example of my Medicare charting on 3-11 shift and 11-7 shift

7/26/05 2200 vs 120/80, 98.6, 70, 20. Resting quietly @ this time. Consumed 100% of meal and 480 cc of fluids per self. No c/o pain or discomfort voiced. No c/o dizziness, headache, or blurred vision voiced r/t htn. No s/s of diabetic crisis noted. BG @ 5 was 150. BG @ 9 was 160. No adverse reaction noted r/t ABT for UTI. No c/o dysuria or foul odor noted. Extra fluids offered throughout shift. No s/s of acute distress.

On the 11-7 shift i chart whether they are sleeping or awake, any complaints of pain and whether or not the person is in acute distress. I hope this helps. Narrative charting is soooo redundant

[CoffeeRTC, BSN, RN]

I forgot...we dont' do monthly summaries anymore. Instead we do a weekly note to coincide with the bath schedul that would include info on the monthly summary. What I do for this is get a copy of a blank mds and make my note answer those questions.

[rebel_red]

Narrative charting is soooo redundant

Ain't it the truth??? Sometimes I just wanna make stuff up...but I like my licence too much so I resist the urge......

Be Well

Tres