Medicare Charting

[mickeypat]

I have a question.... In your LTC facility how often do you document on your Medicare residents? What guidelines do you use? Do you do vitals on them every shift?

At the facility I am currently working at we have to do vitals on each medicare resident, document on them in their chart every shift, even though it's pretty much the same on each night shift. We now have new guidelines that we have to chart on one each resident and it takes almost an hour to do 5 residents!!!!!!! That is just nuts when we have so many other things to do!!!!!! The facility frowns on having any overtime, so we end up donating :angryfire time to the facility or get a stern talking to from management. But then there is one nurse who always is there for at least 2 hours after her shift and c/o not getting her break and that she can never get her stuff done, but never gets "yelled" at...

Am just curious about what other facilities do for medicare... or even managed care...

Thanks

[BearyPrivate]

I have a question.... In your LTC facility how often do you document on your Medicare residents? What guidelines do you use? Do you do vitals on them every shift?

At the facility I am currently working at we have to do vitals on each medicare resident, document on them in their chart every shift, even though it's pretty much the same on each night shift. We now have new guidelines that we have to chart on one each resident and it takes almost an hour to do 5 residents!!!!!!! That is just nuts when we have so many other things to do!!!!!! The facility frowns on having any overtime, so we end up donating :angryfire time to the facility or get a stern talking to from management. But then there is one nurse who always is there for at least 2 hours after her shift and c/o not getting her break and that she can never get her stuff done, but never gets "yelled" at...

Am just curious about what other facilities do for medicare... or even managed care...

Thanks

At our facility we also have to chart,fully assess, and do v/s's on all Medicare patients as well. I am the only nurse at noc and it is a big challenge to get it all done:cry:. I spend about 4-5 hours on documentation alone d/t 16 mdc res in our facility:madface:. I know Medicare only requires once a day but each facility or each director of nursing has their own way of doing things. I think it sucks ,but I love being a nurse.

[proud2b1]

At our facility we chart on our med A and part B from head to toe and anything else pertinent with full vs,every shift!!!!!!!!!

[Rexie68]

we have a grid set up so that every shift gets their fair share of medicare a charting, after the initial 72 hours.

don't ever "donate" your time to the facility. what if you get hurt off the clock? you deserve to be paid for your work! the department of labor, wage and hour division would be interested in your concern.....

[noc4senuf]

Initially every shift for the first 72 hours. We also use a flowsheet, designed by us that covers the entire MDS, it is more of a checklist and has spaces for comments. Narrative charting is required for anything out of the ordinary. After the 72 hours, only days/evenings do the vitals.

[CapeCodMermaid, RN]

At one facility we did q shift charting for 72 hours, then twice daily for 14 days, then once a day after that. The day shift charted on the odd numbered rooms and evenings did the even numbered. Night shift did most of the edits and summaries.

And, of course if anything out of the ordinary happened, that would be charted on, too.

[Talino]

This is not to dispute anyone's routine. I would just like to point out that some facilities maybe doing redundant or unnecessary writing when all is required is proof that the daily skilled service was actually provided.

Depending on the daily skilled service rendered, a nurse's note is not always the absolute source of documentation. I would like to cite examples of daily skilled services that do not necessitate supplementary nurses' notes:

* Rehab Therapies - what's required is an MD therapy order, a therapist's eval'n and therapy plan, and the daily attendance log

* Tube Feeding - MD feeding order, Dietitian's nutrition assm't, a record of daily intake, the signed MAR. Besides, the skilled need for tube feeding is not determined by a daily nurse's note but by the reason for need and the amount of fluid and caloric intake.

* Wound care - MD order for prescription medications and aseptic techniques as delineated in the TAR

* Pressure ulcers (St III or higher or a widespread skin disorder) - MD assm't and tx order, signed TAR, a CNA assignment to turn and position resident or a care plan addressing interventions to facilitate wound healing or prevent new ones.

When a daily skilled service is to observe and assess a patient's unstable medical condition that can not be proven elsewhere then the nurses' note maybe imperative. Albeit, whenever there is an actual change in status or a need to monitor a resident's response to a new treatment, the standard of practice dictates the event/s should always be documented, regardless the service is skilled or not.

This link is from a NY FI (yours may vary) that delineates the sources of information they will request as proof of daily skilled services (see p2) http://www.empiremedicare.com/traina/manual/PET0452.pdf

I know it's hard to uproot an old habit. But if the current routine works for you... heck, go for it.:wink2:

[CapeCodMermaid, RN]

Talino-

As usual you have given us factual information and I always enjoy reading your posts. One thing I smiled at under wound care: MD assessment! HA! We assess all our wounds, describe them to the MD and tell him what treatment we want. Our MD, his PA and his NP are all sorely lacking in wound assessment skills.

And you're right....old habits are hard to break and every facility thinks theirs is the one true way to Medicare nirvana.

[noc4senuf]

Talino, we do not do that excessive documentation in our facility but, jsut follow what is required of the regs.

[TeresaB930, BSN, RN]

We do vitals q shift on all of our Medicare patients as well. Hospitals are having to discharge patients quicker and sicker these days. When we get them in LTC, they are sub-acute. Though most do great, re-coup and go home, a newly diagnosed CHF patient, for example, may show subtle signs of deterioration over a few shifts, that an astute case manager can pick up on and ask for orders to treat.

[husker_rn, RN]

In the skilled facility I worked in we charted once a shift with a set of vitals. We were told our main focus in charting should be the problem that gave them the skilled care; we were also told NOT to chart on things like walking, mobility , etc as that was a PT thing and it could conflict with their charting causing reimbursement troubles.

[flashpoint]

In the skilled facility I worked in we charted once a shift with a set of vitals. We were told our main focus in charting should be the problem that gave them the skilled care; we were also told NOT to chart on things like walking, mobility , etc as that was a PT thing and it could conflict with their charting causing reimbursement troubles.

That is a really good idea. Our biggest problem is that our therapists (we contract out) use a two week flow sheet, so while their documentation is always being done, the sheet doesn't end up in the chart until some of the documentation is two weeks old. Not the best system if you ask me (which no one did :) ) and according to our area manager, I am the only one with a problem with it.

[Talino]

That is a really good idea. Our biggest problem is that our therapists (we contract out) use a two week flow sheet, so while their documentation is always being done, the sheet doesn't end up in the chart until some of the documentation is two weeks old. Not the best system if you ask me (which no one did :) ) and according to our area manager, I am the only one with a problem with it.

'just to clarify...

There is no regulation to have the clinical documentation to support skilled need be in the active medical record at the time of review. When a claim is denied, the contractor or FI will ask the provider to submit documents to prove skilled service. Therefore, the provider may retrieve these documents wherever they normally have it.

Besides, when a claim calls for a medical review, the process will probably take place at least 6 weeks after the PPS/MDS was completed. Thus, a facility has plenty of time to gather all supporting documentations in one place if they so choose.