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Charting guide Charting Documentation Guide Nursing documentation should be clear timely accurate reflective of observations permanent and legible This is a guide and not a complete list Always follow policies in place at your facility Medicare Documentat

Charting Documentation Guide Nursing documentation should be clear timely accurate reflective of observations permanent and legible This is a guide and not a complete list Always follow policies in place at your facility Medicare Documentation ? Must reflect need reason for skilled care ? Must reflect Standard of Care ? Describe intervention s ? Describe resident ? s response to intervention s ? Daily evaluation of progress or lack of progress ? Resident response to skilled therapy ? ADL function ? Changes in condition ? Change Care Plan ASAP after change in condition ? Notification to MD and family Respiratory Pneumonia Medicare Documentation ? Must reflect need reason for skilled care ? Daily vital signs ? Daily and PRN O sat level ? Daily and PRN lung sounds ? SOB with exertion when sitting at rest or when lying flat ? Resident ? s response to interventions and skilled therapy ? Progress or lack of progress ? Change in condition ? Change Care Plan ASAP after condition change ? Notification to MD and family Bladder and Bowel ? Indicate status always continent occasionally incontinent frequent- ly incontinent always incontinent ? Indicate if has catheter indwell- ing or condom intermittent uri- nary ostomy or no urine output ? Toileting program in progress or attempted and outcome ? Constipation Which interventions used and results Anticoagulant Therapy Medicare Documentation ? Must reflect need reason for skilled care ? Daily vital signs ? Monitor for bleeding bruises ? Monitor lab values Be sure PT INR drawn per physician order and reported to MD ? Monitor sudden dyspnea chest pain temp or color change in extremities ADLs ? How does resident perform ?? Bed mobility ?? Transfers ?? Ambulation ?? Dressing ?? Eating ?? Toileting and personal hygiene ? How much staff support is needed ?? Independent ?? Set up help only ?? One person ?? Two person physical assist ?? Activity does not occur ? Document support needed for ADLs over all shifts ? Which interventions used to compensate for ADL deficit i e walker w c cane Change in Condition Requiring a New Intervention ? Time Date ? Change that has occurred i e weight loss pressure ulcer cognition overall deterioration ? Which ADLs are affected ? Which intervention applied ? Response to intervention ? Was MD or family notified Fracture Hip Medicare Documentation ? Must reflect need reason for skilled care ? Daily vital signs including pain ? ADL ability assistance needed use MDS Language ? Monitor incision site ? Indicate resident ? s response to therapy pain fatigue etc Behavior Assessment Documentation ? Date Time ? Location ? Specific behavior ? Who is around ? Any triggering event loud noises new staff providing care ? How do symptoms interfere with ADLs ? How does it interfere with care ? Rule out hunger toileting needs pain boredom medication ? If has respiratory diagnosis ?? O sat level ? Non-medication intervention ?? resident response ? Medication intervention if needed ?? document response ?