Skilled Nursing Documentation
Harmony educates many professionals in the long term care industry and stresses that "you must walk before you run." In other words, to compose nursing documentation that clearly depicts the provision of daily skilled nursing care you must have an understanding of the Medicare regulations which define skilled care.
Care in a SNF is covered if all of the following three factors are met:
The patient requires skilled nursing services or skilled rehabilitation services; i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§214.1 - 214.3);
The patient requires these skilled services on a daily basis (see §214.5);
As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in an SNF (see §214.6).
Harmony stresses that daily skilled nursing documentation and services should anchor skilled coverage.
Daily skilled nursing documentation should:
Focus their assessment and observation on systems/problems with signs and symptoms of acute illness.
Identify the conditions that are becoming unstable.
Identify and communicate the resident's problems, needs and strengths.
Record specific treatments given and response to treatment
Describe positive nursing findings; e.g., "respiratory assessment revealed crackles in the lungs, nursing action taken: increased liquids encouraged coughing and deep breathing, etc."
Describe negative findings; e.g., "no chest pains, no cyanosis."
Document vital signs, if abnormal, describe the nursing action taken.
Determine whether the abnormal signs are chronic or acute.
Describe the patient's response to treatment. Taking antibiotics, describe the condition for which the antibiotics are being administered, as well as the patient's signs and symptoms related to that condition.
Evaluate new medication and any side effects.
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