Medicare charting

[Blackcat99]

Does anyone know if there is a book I could purchase that would tell me exactly what to chart in order to please medicare.? I really don't know what they want. I work in LTC and am hoping there is a book somewhere where I could look up a diagnosis and find real examples of what they want to read in the charts. Thanks

[leslie :-D]

Does anyone know if there is a book I could purchase that would tell me exactly what to chart in order to please medicare.? I really don't know what they want. I work in LTC and am hoping there is a book somewhere where I could look up a diagnosis and find real examples of what they want to read in the charts. Thanks

if you have to do daily notes on patients receiving skilled care, medicare wants the notes to reflect the pt's condition/status, all skilled care applied by nsg, pt/ot and other skilled services; what the pt. is doing in terms of adls ambulating eating and all pertinent information related to why patient was hospitalized....for example, if patient was hospitalized because of fx'd hip:

"pt. baseline confused; appears to be in pain as evidenced by increased agitation and restlessness, vicodin 1 tab given w/effect. max assist with adls; pt in and got pt oob to chair x 1 hr. pt tolerated well. suture site sl red with sm amt serous drainage noted on old dsg. appetite remains poor and rejected favorite foods. continent of bladder, no bm x 3 days. gave mom30cc po this shift with results pending. refer to rehab notes for pt progress."

so the above note addresses and justifies the reimbursement that medicare is paying the facility to the patient. hopefully that helped a bit.

leslie

[Blackcat99]

:) Thanks Leslie. You have been very helpful.