Medicare charting is necessary for confirmation of the services needed for the continuation of skilled care. Nursing staff must chart Medicare A residents once every 24 hours. Most facilities divide that charting between day and evening shifts. The charting should include vital signs, why the resident is receiving skilled services, and an excellent description of the resident's condition at that time. The nursing narratives should define the medical and nursing rationale for skilled services (Mastrangelo, 2016).
Writing a nursing note takes some thought. It would be wise to remember to use your critical thinking skills. Think before you write! If you make a mistake or forget to write something, you can always write a late entry. Remember, the notes you write are legal documents.
It is your duty to protect yourself, the facility, and the resident (Schmidt, 2019). Medicare charting may be more frequent if necessitated by the resident's condition. The documentation content is specific to the clinical reasons for coverage and services delivered and should be objective and measurable. Medicare worksheets can help focus charting the specific service delivered, related clinical issues, and the resident's response to care (AHIMA, 2001).
The four pillars of Medicare charting include (Schmidt, 2019):
- Inherent Complexity:
- These are the services only a nurse can provide: IV feeding, IV meds, suctioning, tracheostomy care, ulcer care, tube feedings, care for surgical wounds, and diabetes management with injections.
- Observation and Assessment:
- Observation and assessment include complications, the potential for further episodes, and evaluation of initiation of additional medical procedures.
- Management and Evaluation of a Care Plan:
- The care plan gives a good picture of the plan to improve a resident's health needs and can be modified when a condition changes. Nurses are responsible for charting the services that require the involvement of skilled nursing care. These services must meet the resident's needs, promote recovery and ensure medical safety.
- Teaching and Training:
- Teaching and training are always a part of skilled nursing care and a Medicare requirement and must involve the resident and the family whenever possible. Teaching includes colostomy care, insulin administration, prosthesis management, catheter care, G-tube feedings, IV access sites, and wound care. Healthcare professionals are teachers at all times in any clinical setting.
Remember, one great nursing note is better than a string of unnecessary fillers that do not support the need for skilled services (HHI, 2021). Chart only why the resident needs skilled services, what you are doing to promote healing, and is it working? Ensure that skilled treatments are being charted and why the treatments are needed (besides a physician's order!)
A very problematic area is charting adverse events such as falls. When documenting in a resident chart, never chart "incident report done" as this is a red flag to surveyors. Document the fall, what was seen, any injuries, and what was done for the resident if there were injuries. You must also document your call to the physician and the family. Just state the facts!
Other documents include weekly and monthly summaries of each resident. A summary is information on what you are doing to show the residents' progress or lack of progress. The summary note should be based on the care plan. If there are changes in the resident's status from the previous summary, the care plan must be updated (AHIMA, 2014).