Medicare charting newbie, need info


I am new to LTC and really starting to :redbeathe it! However, I have the medicare hall, and I am wanting to make sure I'm hitting all the bases. We have a checklist type thing on the front with all of the info from the assessment, vitals for each shift at the top, and the res. ability to perform ADLs that we grade with numbers. All of these criteria for day, evening, and night, and then on the back we write a narrative. The back is split into three boxes as well, for day, evening and night. However, I have had no education on medicare. The training I've gotten from the facility is to chart on their diagnosis and their ability to perform adls. I would really like more information. Could anyone suggest any websites or books, anything really, that would clearly explain to me what needs to get posted so that we are properly reimbursed? (and, of course, so I don't look like a moron?:D) TIA!!

Specializes in Med/Surg, LTC.

Oh, and I'm in TX, if that helps :)

I am also in Tx and work on a skilled unit in LTC. The main thing they are looking for is HOW the resident participates in ADLs. Min. or Max assist. 1 or 2 person. Do they bear wt? Do the wash themselves?

ie: res is A&O X3 able to make needs known. Up in wheelchair to DR for meal. Able to feed self but requires set-up of tray. transfered to toilet with walker and one person assist for balance. Needs assist to adjust clothing. Wears incontinent pads d/t occ. episodes of bladder inc. Shower done this evening with assist of one. Able to wash face, and front of body. Unable to wash lower body.

Hope this helps.


547 Posts

Specializes in LTC, MDS, Education.

Hey student, you have posted a very good question and it seems like you are on the right track. Find out who the MDS coordinator is. Stay a few minutes and "pick her brain". You will find out alot and have a GREAT resource person! I do MDS and love to give tips and suggestions as it makes my job alot easier when I read your notes. When I have to enter the data in the computer for medicare reimbursement, it makes my job soooo much easier if you have included such things as: Do they talk? Are they continent? Do they c/o pain?


230 Posts

Specializes in Med-Surg., Agency Nursing, LTC., MDS..

Great question ! ADL's are real important and chart the skilled observations pertaining to the specific dx's/reasons they are on Med. A. Also, are they going to PT/ OT. ? Did they tolerate it okay ?

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