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

Charting Documentation Guide Nursing documentation should be clear timely accurate re ective 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 re ect need reason for skilled care ? Must re ect 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 ? Noti ?cation to MD and family Respiratory Pneumonia Medicare Documentation ? Must re ect 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 at ? Resident ? s response to interventions and skilled therapy ? Progress or lack of progress ? Change in condition ? Change Care Plan ASAP after condition change ? Noti ?cation to MD and family Bladder and Bowel ? Indicate status always continent occasionally incontinent frequently incontinent always incontinent ? Indicate if has catheter indwelling or condom intermittent urinary ostomy or no urine output ? Toileting program in progress or attempted and outcome ? Constipation Which interventions used and results Anticoagulant Therapy Medicare Documentation ? Must re ect 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 Fracture Hip Medicare Documentation ? Must re ect 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 ADLs ? How does resident perform ?? Bed mobility ?? Transfers ?? Ambulation ?? Dressing ?? Eating ?? Toileting and personal hygiene ? How much sta ? 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 de ?cit 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 a ?ected ? Which intervention applied ? Response to intervention ? Was MD or family noti ?ed Behavior Assessment Documentation ? Date Time ? Location ? Speci ?c behavior ? Who is around ? Any triggering event loud noises new sta ? providing care ? How do symptoms interfere with ADLs ? How does it interfere with care ? Rule out hunger toileting needs pain boredom medication changes ? If has respiratory diagnosis ?? O sat level ? Non- medication