The purpose of this course is to help nurses correctly complete process in long-term care documentation and to recognize the importance of accurate charting.
After completing this course, the learner will be able to meet the following objectives:
Documentation in long-term care has become increasingly complex as the resident’s clinical needs and decision making have become more complex, regulations and surveys more stringent, documentation based payment systems implemented, and litigations/legal challenges have increased.1 Remember, if it isn’t documented, it isn’t done!
Federal regulations dictate the types of documentation. Federal regulation (FS14) requires that a facility “must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized.1” The nurse must be careful and take the time to document accurately, staying within the facility requirements.
The admission record face sheet must include the demographic information for each resident and is usually completed by the admissions office. Included on the “face sheet” is the following information:
After the resident gets to the unit, the admitting nurse checks the face sheet to ensure all needed information is included. Before performing assessments, the nurse orients all new residents to the unit, introduce staff and explains the daily routine.
Make sure the nurse has all the tools necessary. The nurse can make the new residents nervous, and it devalues the nurse’s competence if she has to keep running back and forth while doing the assessments.
The nurse can begin a head-to-toe assessment just by looking at the resident, listening to the resident’s speech pattern and checking memory by asking a few short questions: Do you know where you are? What is today’s date? Facial features? Drooping mouth? Be aware of what you are seeing when doing a visual inspection!
Vital signs, including the oxygen saturation, weight and height must be documented. Has the resident had a recent weight loss or gain?
Now let’s start the head-to-toe assessment. When checking the resident’s head, be sure to look behind the ears, especially if the resident is using oxygen, as the tubing can cause sores. Look at the eyes; pupils equal and reactive? Are there visible sores in the mouth? Does the resident have good dentition or dentures? Auscultation of lungs: Accurately describe breath sounds, i.e., wheezes, rales, rhonchi. Assess respiratory rate, rhythm, and quality. Does the resident have good bowel sounds? When did resident have last bowel movement? Pain in abdomen? Is the abdomen soft and non-tender? As the assessment continues, move down to the legs and feet: Any discoloration on legs? Pain in legs? Cramps? Are the feet blue/purple? Can you locate the pedal pulses? Are there any sores on the feet?
Once you have finished the head-to-toe assessment you can begin all the other assessments, and, yes, there are a lot of them!
The Morse Fall Scale is a rapid and simple method of assessing the resident’s likelihood of falling.2 The scale is easy to use and has six variables, and it has shown to have predictive validity.2
History of Falls:
Total Score: Tally the patient score and record.
0: No risk of falls
<25: Low risk
25-45: Moderate risk
>45: High risk
* Weak gait: Short steps (may shuffle), stooped but able to lift head while walking, may seek support from furniture while walking, but with light touch (for reassurance).
† Impaired gait: Short steps with shuffle; may have difficulty arising from chair; head down; significantly impaired balance, requiring furniture, support person, or walking aid to walk.2
Once the Morse Fall Scale is complete, it is time to move on to the skin assessment. This assessment is more complicated, as you will use the Braden Scale, but also you will be assessing the skin condition.
The Braden scale is used to foster early identification of at risk residents for forming pressure sores.3
|Patient's Name||Evaluator's Name||Date of Assessment|
ability to respond meaningfully to pressure-related discomfort
|1. Completely Limited|
Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation.
limited ability to feel pain over most of body surface.
|2. Very Limited|
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.
has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body
|3. Slightly Limited|
Responds to verbal commands, but cannot always communicate discomfort or need to be turned.
has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
|4. No Impairment|
Responds to verbal
commands. Has no
sensory deficit which would
limit ability to feel or voice
pain or discomfort.
degree to which skin is exposed to moisture
1. Constantly Moist
2. Very Moist
3. Occasionally Moist
|4. Rarely Moist|
Skin is occasionally moist, requiring
an extra linen change approximately
once a day.
degree of physical activity
|3. Walks Occasionally|
Walks occasionally during the day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.
|4. Walks Frequently|
Walks outside room at least twice a day and inside room at least once every two hours during waking hours.
ability to change and control body position
1. Completely Immobile
|2. Very Limited|
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
|3. Slightly Limited|
Makes frequent though slight
changes in body or extremity
|4. No Limitations|
Makes major and frequent
changes in position without
usual food intake pattern
|1. Very Poor|
Never eats a complete meal.
Rarely eats more than a of any
food offered. Eats 2 servings or
less of protein (meat or dairy
products) per day. Takes fluids
poorly. Does not take a liquid
is NPO and/or maintained on
clear liquids or IV=s for more
than 5 days.
|2. Probably Inadequate|
Rarely eats a complete meal and
generally eats only about 2 of any
food offered. Protein intake
includes only 3 servings of meat or
dairy products per day.
Occasionally will take a dietary
receives less than optimum amount
of liquid diet or tube feeding.
Eats over half of most meals. Eats
a total of 4 servings of protein
(meat, dairy products per day.
Occasionally will refuse a meal, but
will usually take a supplement when
is on a tube feeding or TPN
regimen which probably meets
most of nutritional needs.
Eats most of every meal.
Never refuses a meal.
Usually eats a total of 4 or
more servings of meat and
Occasionally eats between
meals. Does not require
|FRICTION & SHEAR||1. Problem|
Requires moderate to maximum
assistance in moving. Complete
lifting without sliding against
sheets is impossible. Frequently
slides down in bed or chair,
requiring frequent repositioning
with maximum assistance.
Spasticity, contractures or
agitation leads to almost
|2. Potential Problem|
Moves feebly or requires minimum
assistance. During a move skin
probably slides to some extent
against sheets, chair, restraints or
other devices. Maintains relatively
good position in chair or bed most
of the time but occasionally slides
|3. No Apparent Problem|
Moves in bed and in chair
independently and has sufficient
muscle strength to lift up
completely during move. Maintains
good position in bed or chair.
To score the Braden Scale, add up the numbers in column to the right5:
15-18= preventative measures- at risk (regular turning schedule, protect heels, manage moisture)
13-14= preventative measures- moderate risk-use same protocol as at risk, but add foam wedges to off-set pressure points
10-12-Preventative measures-high risk-same protocol as moderate risk, add regular turning schedule, make small shifts in position frequently
9 or less=very high risk-add a pressure redistribution surface for residents with severe pain.
When performing a proper skin assessment, there are five elements to assess6:
The Medication administration record (MAR), whether on paper or the computer, is an important part of the admission process. After checking the physician’s orders, enter all the medications onto the MAR, along with the diagnosis. If there is no diagnosis, please check with the physician to clarify. Be sure to enter the correct times, dosage, and route. Remember to enter all immunizations. Ensure that vital signs are recorded for cardiac medications on the MAR. Diet orders must be entered. If a G-tube is in place, what feeding is ordered? What is the timing? What flushes are ordered?
The treatment sheet follows the same rules, remember to enter the monthly weights! If your facility still uses paper, ensure all boxes checked before the end of your shift. Remember, if it is not documented, it is not done! If you are using a computer, be sure to check the program before the end of shift to ensure all meds are given.
Bowl and bladder is an important assessment for a long-term resident. It is imperative to complete an accurate picture of the resident’s continent/incontinent status. This assessment is completed over a 72-hour time frame. If a resident is admitted with an indwelling catheter, you will need medical justification, type and size of catheter, potential for removal, color of the urine and the flow of the urine.1
The continent/incontinent status can be obtained by asking the resident and by observation. Does the resident use Depends? Is there a urine odor present? Review the diagnoses and medications to see if there is a condition that may affect continence.
If the resident is incontinent, routine skin care must be documented on the treatment sheet. If the resident is alert and aware, make a referral to Occupational Therapy for bowel and bladder retraining.
Activities of daily living (ADL) are the basic tasks that must be accomplished every day for the resident to thrive.7 There are five categories7:
IADLs, instrumental activities of daily living are somewhat more complex but also reflect on a person’s ability to live and thrive.7 There are seven categories, but some are not pertinent to long-term care. We will only explore the ones necessary for the long-term care setting.
Companionship and mental support: This a fundamental IADL for daily living. It reflects on the help needed to keep a person in a positive frame of mind.7 This is especially important in the long-term setting.
Communicating with others: Can the resident speak and understand others? Is the resident hard of hearing? Does the resident like big or small groups?
Other aspects of the ADL assessment include the resident’s interests and hobbies, spirituality, preferences, and needs. Social services and Activities department’s assessment will go into depth with the resident regarding life roles, occupation and other interests.
In an effort to identify and meet the needs of new clients admitted to Greatest Long Term Care Center in the World, located in Central Florida, the Rehab Director reviews nursing documentation that was collected upon admission.
The Geriatric Depression Scale is a self-report measure of depression in older adults.8 Most facilities use the short form, which consists of 15 items, and can be completed in about 5 minutes.
Patient’s Name: Date:
Hearing and vision deficits impact the everyday life of residents including independence and social participation.9 The easy way to assess hearing is to observe reactions from the resident; can he hear what is being said? Does he have hearing aids? If not, does he want hearing aids?
Vision can be tested by having the resident read a short note or a newspaper. Does the resident wear glasses? Are they helpful? If the resident reports that he may need “stronger glasses” he will need a referral to an eye doctor.
After the nurse has completed the admission assessment, the CNA will help the resident put personal items away, and to put the resident’s name on all clothing. An inventory sheet must be completed on admission.
Mrs. Jones was admitted to the facility in the early morning, coming from home. The family had packed enough outfits for 8 days. Susan, the CNA on the unit, helped Mrs. Jones unpack and to put her things away when she was called out of the room for an emergency. After breakfast, Susan had planned to finish unpacking for Mrs. Jones, but got so busy she forgot, and by the end of the shift, Susan had not finished the inventory sheet. Right after supper, as Mrs. Jones was returning to her room, she noticed another resident wearing her sweater. Mrs. Jones told the staff, but because there was no name on the tag, and Mrs. Jones was new and the evening staff was not familiar with her yet, she did not get her sweater back. In the morning, when Mrs. Jones’ daughter came to visit, the staff showed her the sweater to confirm it was her mom’s. If the inventory sheet had been finished, and the resident’s name had been put in each piece of clothing, Mrs. Jones would have not been upset.
After all the assessments are completed, the resident teaching needs to be documented. Next, the Interim Care Plan must be finished. The diagnoses should be included in the interim care plan, as well as what will be addressed in the resident’s care, and how this care will be accomplished. Remember, the interim care plan will be shared with all disciplines, and is used as a base for the long-term care plan.
Medicare charting is necessary for confirmation of the services needed for the continuation of skilled care. Nursing staff must chart on Medicare A residents once every 24 hours. Most facilities divide that charting between day and evening shift. 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.11
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.10 Medicare charting may be more frequent if necessitated by the resident’s condition. The content of the documentation is specific to the clinical reasons for coverage and services delivered and should be objective and measurable. Medicare worksheets can be helpful in focusing charting to the specific service delivered, related clinical issues, and the resident’s response to care.13
The four pillars of Medicare charting include:
Remember, one great nursing note is better than a string of unnecessary fillers that do not support the need for skilled services.12 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!)
An area that is very problematic is charting adverse events such as falls. When documenting in a resident chart, never chart “incident report done.” 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 to the family. Just state the facts!
Other documents include weekly and monthly summaries on each resident. This 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.1
Documentation in the long-term setting is regulated by Federal regulation (FS14). Documentation should be complete, accurate, readily accessible and systematically organized. The admission assessments are lengthy but are important as these assessments create a picture of the resident’s overall condition.
Medicare charting is necessary for confirmation of the services needed for the continuation of skilled care. Nursing staff must chart on Medicare A residents once every 24 hours. You must use critical thinking when writing notes. Remember that the notes you write are legal documents.