Charting Guidelines for Nursing Charting - PDF by ggz17956

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									                                      TABLE OF CONTENTS

  Medicare Skilled Nursing Training Handout...........................................................Section 1
   • Post Test ..........................................................................................................1
   • Training Content .............................................................................................3
   • Nursing Documentation Subjective/Objective Statements ............................22
   • Supportive Nursing Documentation................................................................23
   • Medicare Skilled Coverage Checklist .............................................................26
   • Case Studies ....................................................................................................36


  Skilled Level of Care Criteria Management …………………...............................Section 2
   • Medicare Coverage Chart................................................................................1
   • Continued Stay Requirements & Documentation ...........................................2
   • Stand Up Report .............................................................................................7
   • Weekly Meeting Tool .....................................................................................9
   • SNF Level of Care ..........................................................................................13


  Medicare Charting Guidelines.................................................................................... Section 3
     • Documentation Guideline Procedures ........................................................1
     • Medicare Documentation Guidelines .........................................................2




Manual includes:

Manual CD - Includes forms and charting guidelines in Word

Audio CD - Training audio CD, listen to audio CD while reviewing the manual material.
This audio CD walks you through the material to provide training to skilled level of care. It is
strongly recommended that the audio training CD be used to compliment the training experience.
It is suggested that staff development listen to CD prior to providing training for front-line staff.
Another option is to play the CD for all front-line staff.
                                               Medicare Skilled Nursing Documentation
                                                                                      ___________________________________

                      Eligibility Requirements                                        ___________________________________
                                                                                      ___________________________________
                Three (3) consecutive midnight stay as an inpatient in an acute
                care hospital                                                         ___________________________________
                  – Acute                                                             ___________________________________
                  – Psych
                  – Rehab                                                             ___________________________________

                Daily Skilled Service Provided by Licensed Personnel
                                                                                      ___________________________________

                As a Practical Matter must be provided in a SNF

   Developed by Polaris Group (800) 275-6252                                      1




                                                                                      ___________________________________




                                                                                  LE
                      Additional Requirements                                         ___________________________________
                                                                                      ___________________________________
                 Skilled Services provided pursuant to a physician’s order
                                                                                      ___________________________________
                 Physician Certification required at admission, on or before
                                                                                      ___________________________________
                                                                P
                 day 14, and every 30 days thereafter.
                                                                                      ___________________________________
                 The beneficiary must be admitted to the SNF for skilled
                                                                                      ___________________________________
                                                 M
                 care within 30 days of hospital discharge – 30 day transfer
                 rule. The exception to this is medical predictability.
                                   A

   Developed by Polaris Group (800) 275-6252                                  2




                                                                                      ___________________________________
                                  S



                             Practical Matter Test                                    ___________________________________

                Based on the individual’s condition and the availability
                                                                                      ___________________________________
                and feasibility of using more economical alternatives.
                                                                                      ___________________________________
                As a practical matter skilled services can only be provided
                in a SNF if they are not available on an outpatient bases
                OR……
                                                                                      ___________________________________
                If transportation to the closest facility would be:                   ___________________________________
                 – An excessive physical hardship
                 – Less economical                                                    ___________________________________
                 – Less efficient or effective than an in-patient
                    institutional setting

   Developed by Polaris Group (800) 275-6252                                  3




Polaris Group (800) 275-6252                                                                               Page 5 of 40
                   Nursing Documentation Subjective/Objective Statements

 #    Subjective Statement                       Objective Statement

1.    Cannot follow simple command of            Requires direct supervision to walk into the bathroom and with
      “go into bathroom and brush your           toothbrush placed in hand, resident will brush teeth.
      teeth”.
                                                 When a single food item and one utensil are given to resident,
                                                 he will eat independently.

                                                 When the CNA hands the resident a sock and told to put it on
                                                 his foot, the resident can do so.

2.    Resident demanding today.                  On call bell 15 times in ½ hour.

3.    Combative.                                 Biting, scratching and kicking.




                                                      LE
                                                 Striking out at CNAs during a.m. care.
                                                 Able to prepare injection site aseptically, independently but
4.    Poor learner, slow learner.                requires verbal cueing.

      Appears to understand.                     Able to return demonstration.
                                             P
5.    Choking after every few bites of           Coughing and clearing throat after every two - three bites of
                                  M
      food.                                      food.

6.    Small amount of drainage on                Dime size (or measured amount) of green purulent drainage.
                  A


      dressing.

7.    Antibiotic therapy continues.              Lung sounds clear, no nausea or vomiting, no skin rash noted
                 S



                                                 T________ P ________ R ________


8.    Wound healing well.                        Wound bed 5 cm in circumference and 1 cm in depth. Pink
                                                 granulation tissue noted 2 cm around inside circumference. 1
                                                 cm open area noted in center of wound bed. Open area is red
                                                 with no drainage or odor. Skin surrounding wound intact. Pain
                                                 during treatment note at a pain scale of 5, Tylenol given prior
                                                 to treatment.




     Developed by Polaris Group (813) 886-6500                                                         1.1
                          SUPPORTIVE NURSING DOCUMENTATION
                                                PHYSICAL THERAPY

    Overview:       The following chart provides examples of how to document progress at least
                    weekly in specific physical therapy situations.

FUNCTIONAL SKILL              NURSING DOCUMENTATION EXAMPLE
Bed Mobility                  Resident holds onto side rails to pull self onto side.

                              Two CNAs move resident up in bed with use of turning sheet and extensive
                              assist.

                              Resident requires limited assist to sit up in bed and to swing legs over side
                              ending in a sitting position.
Supine to Sit --> Stand       Resident can pull self to a sitting position with use of side rails. Can swing right
                              leg to floor. CNA moves left leg to floor. Needs assist of 2 to lift resident from a




                                                    LE
                              sitting to standing position. Once standing can pivot to wheelchair and sit
                              independently.


Transfers                     Transfers from bed to wheelchair with limited assist and cueing of 1, to remind
                                            P
                              resident not to bear weight on left leg.

                              Requires 2 to transfer, lifting resident from bed to chair.
                                 M

                              Need extensive assist of one and will pivot once lifted to a standing position.
                 A


                              Resident can rise from chair with limited assist, but must be lowered into chair
                              with weight bearing support.
                              Ambulates 20 feet in hallway with 2 CNAs, limited assist is provided with one
                S



Ambulation
                              holding gait belt and one following behind with wheelchair. Resident ambulates
                              bent at waist and will sit down without warning.

                              Ambulates in room independently pushing wheelchair as support, requires one
                              limited assist to ambulate in hall to dining room.
Range of Motion               Passive ROM provided by CNA during PM care to both upper extremities.
                              Splint applied and therapeutic positioning provided to upper extremities as
                              directed by therapy. Tolerated well.




    Developed by Polaris Group (813) 886-6500                                                         1.1
                          MEDICARE DOCUMENTATION GUIDELINES
NAME:_____________________________________ ADMISSION DATE TO CERTIFIED SECTION: ______________


RESIDENT/BENEFICIARY IS COVERED BY MEDICARE FOR: ___________________________________________


THE HIGHLIGHTED AND/OR HANDWRITTEN AREAS HAVE BEEN IDENTIFIED AS THE BASIS FOR MEDICARE
COVERAGE. PLEASE ADDRESS THESE AREAS IN THE DAILY NURSING, AS WELL AS OTHER PROBLEMS OR
CONCERNS REGARDING THE RESIDENT/BENEFICIARY’S CARE OR CONDITION.


CANCER

 1. Vital signs Q _____________________

 2. BP & Pulse Q shift

 3. Anorexia




                                                            LE
 4. I & O, note fluid retention

 5. Weight

 6. Apprehension
                                                    P
 7. Skin; odor from affected tissue (Wound Care)
                                        M
 8. Attitude; fatigue

 9. Pain; location, type, duration, time it occurred, how
    treated results of treatment (medication, comfort,
    measures, etc.)
                      A


 10. Activity, mobility
                     S



 11. Sensitivity to chilling

 12. If on Chemo/Radiation; report nausea, vomiting

 13. Positioning techniques
                         MEDICARE DOCUMENTATION GUIDELINES
NAME:____________________________________ ADMISSION DATE TO CERTIFIED SECTION: _______________


RESIDENT/BENEFICIARY IS COVERED BY MEDICARE FOR: ___________________________________________


THE HIGHLIGHTED AND/OR HANDWRITTEN AREAS HAVE BEEN IDENTIFIED AS THE BASIS FOR MEDICARE
COVERAGE. PLEASE ADDRESS THESE AREAS IN THE DAILY NURSING, AS WELL AS OTHER PROBLEMS OR
CONCERNS REGARDING THE RESIDENT/BENEFICIARY’S CARE OR CONDITION.



      OBSERVATION & ASSESSMENT OF CHANGING CONDITION

 1. SKIN CONDITION                                       D. Genitourinary
    A. Integrity                                               1. Continent/incontinent
 B. Measure and describe open areas or potential               2. Candidate for bladder training
    problems                                                   3. Foley catheter? Why?




                                                         LE
                                                               4. Color, odor, sediment
 2.   PHYSICAL AND FUNCTIONAL STATUS
      A. Documentation assistance required for bed       5.   RESPONSE TO TREATMENT
         mobility, positioning, transfers, ambulation,        A. Document response to any change in
         endurance level with activity, ADLs                     medication, e.g., cardiac, psychotropic,
      B. Rehab evaluation (s) as appropriate:                    pain
                                                     P
 1.   PT                                                      B. Response/progress regarding treatments
 2.   OT
 3.   ST                                                 6.   GENERAL NURSING OBSERVATION
                                         M
                                                              A. Note all observation that evaluate and
 3.   NUTRITION/HYDRATION STATUS                                 identify needed changes or modifications
 A.   Eating/swallowing impairment                               in beneficiary care plan
 B.   Skin turgor                                             B. Document contact with the attending
 C.   Special dietary needs                                      physician and any resulting action
                       A


 D.   Percent meals eaten/day

 4. SYSTEM ASSESSMENT
                      S



 A. Mentation
 1. Oriented times ____
 2. Ability to follow instructions
 B. Cardiac and Respiratory
        1. Body edema
        2. Irregularities of pulse/apical/radial
        3. Presence of wheezing, rhonchi by
             auscultation
        4. SOB, cough, sputum
 C. Gastro Intestinal
 1. Bowel sounds present
 2. Gas, constipation, loose stools
 3. Nausea
 4. Hiatus, belching
 5. Feeding tube-why?
                          Checklist for Assisting with Determination of Medicare Skilled Coverage


Beneficiary Name:

Medicare Condition/Diagnosis

IN ORDER TO DETERMINE IF THE PATIENT MEETS THE CRITERIA FOR MEDICARE COVERAGE,
PLEASE COMPLETE THE FOLLOWING QUESTIONNAIRE BY ANSWERING YES OR NO:

 1) Three (3) midnights in-patient qualifying hospital stay or prior SNF stay? ______

      If YES, give dates of service for all prior stays and verify # of SNF days used.
      NOTE: After 100 days of SNF coverage, benefits are exhausted.

      If NO, STOP, resident is NOT Medicare qualified.

 2) IS QUALIFYING HOSPITAL STAY OR PRIOR SNF STAY WITHIN 30 DAYS OF THIS ADMISSION DATE?
    ______

     If YES, continue to #3, if NO, STOP, patient is NOT Medicare qualified.

     NOTE: ONE EXCEPTION TO THE 30 DAY RULE-MEDICAL APPROPRIATENESS EXCEPTION - AN ELAPSED




                                                              LE
     PERIOD OF MORE THAN 30 DAYS IS PERMITTED FOR SNF ADMISSIONS WHERE THE RESIDENT’S
     CONDITION MAKES IT MEDICALLY INAPPROPRIATE TO BEGIN AN ACTIVE COURSE OF TREATMENT IN
     AN SNF WITHIN 30 DAYS AFTER HOSPITAL DISCHARGE, AND THIS IS ORDERED AT TIME OF DISCHARGE
     FROM HOSPITAL.

 3) DOES THE RESIDENT REQUIRE 7 DAYS OF SKILLED NURSING OR 5 DAYS OF THERAPY (CAN BE A
                                                    P
    COMBINATION OF PT, OT, and ST)? _______

     If YES, continue to #4, if NO, STOP, patient is NOT Medicare qualified.
                                        M

 4) IS THERE A PHYSICIAN ORDER FOR THE SNF ADMISSION? ______

     If YES, continue to #5, if NO, contact physician regarding patient’s eligibility status.
                     A


 5) AS A PRACTICAL MATTER, IS A SKILLED NURSING FACILITY THE MOST APPROPRIATE PLACE FOR
    RENDERING CARE? ______
                    S



     Answer must be YES, continue to #6.


 6) IS RESIDENT IN A MEDICARE CERTIFIED BED? ______

     If YES, continue to next section, if NO, NOTE: Medicare patients must be placed in a Medicare certified bed in order to be
     covered.




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