Harmony Healthcare Blog

Skilled Nursing Documentation (Part 1): The Four Pillars

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Mon, May 23, 2016
Kris Mastrangelo, OTR/L, LNHA, MBA
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documentation_medicare.jpgThe importance of facility wide comprehension of Medicare Coverage Criteria is a high priority focus for facility managment.  The below four pillars are the foundation for which skilled nursing services anchor the Medicare Part A patient’s coverage and SNF stay. Understanding these elements leads to proper documentation. 

Regardless of the patient’s RUG Category (Nursing or Rehabilitation), the nursing narratives needs to define the medical and nursing rationale for skilled services.  Back in 1998 with the advent of PPS, the industry encountered a huge lapse in the foundation for Medicare Coverage.  (The BIPA – Beneficiary Improvement Protection Act) reinstated the original criterion). 

The confusion in 1998 was compounded by the addition of the Medicare Part A RUGs Presumptive Coverage Criterion implying that a beneficiary’s stay was simply based on the MDS generated payment level.  (Not considering if the MDS was inaccurately coded……and this went both ways).  The Presumptive Coverage Criterion combined with the removal of the four pillars (later restated in 2001), impacted the industry for a period of almost 2 years! The long term care industry struggled with what constituted Medicare Part A coverage.  Soon thereafter, the regulations clarified that yes indeed, the below four pillars are the cornerstone of skilled services.

Harmony Healthcare International (HHI) encourages the sharing of the below information with all facility staff caring for the Medicare Beneficiary.  This knowledge will exponentially enhance service delivery and perfect the documentation necessary for accurate and appropriate reimbursement. 

1.  Inherent Complexity:

This references services that “only a nurse can provide” including, but not limited to: 
  • IV feeding,
  • IV meds,
  • suctioning,
  • tracheostomy care,
  • ulcer care,
  • tube feedings,
  • respiratory therapy,
  • care for surgical wounds or open lesions,
  • management of diabetes with injections,
  • transfusions,
  • chemotherapy and
  • early post operative colostomy care. 

In these situations, the nurse may write: 

“This patient requires daily skilled nursing secondary to the inherent complexity of wound care.”

2.  Observation and Assessment:

This references conditions where there is a “reasonable probability or possibility” for:
  • complications,
  • potential for further acute episodes,
  • the need to identify and evaluate the need for modification of treatment,
  • evaluation of initiation of additional medical procedures

Observation and assessment Includes, but is not limited to, fever, dehydration, septicemia, pneumonia, nutritional risk, chemotherapy, weight loss, blood sugar control, impaired cognition, mood and behavior conditions.

In conjunction with identifying the nursing assessment, it is imperative to document the defined assessment on a daily basis.  This may include neurological, respiratory, cardiac, circulatory, pain/sensation, nutritional, gastrointestinal, genitourinary, musculoskeletal, and skin assessments.

In these situations, the nurse may write:

“This patient requires daily skilled nursing observation and assessment of signs and symptoms related to exacerbation of pneumonia.” 

Remember:  Skilled observation is required until the treatment regimen is essentially stabilized.

3.  Management and Evaluation of a Care Plan:

This references the patient’s total condition.  Based on the Physician’s orders, these services require the involvement of skilled nursing to: 
  • meet the resident’s medical needs,
  • promote recovery, and
  • ensure medical safety. 

This area includes the: 

  • sum total of unskilled services,
  • potential for serious complications,
  • high probability of relapse,
  • recovery and safety,
  • meet medical needs,
  • includes resident’s overall condition. 

Nursing narratives may elaborate on surgical sites, circulatory status, status of fractures, maintenance of weight bearing status, skin care and labs. 

In these situations, the nurse may write: 

“This patient requires daily skilled nursing for overall management and evaluation of care plan to ensure medical safety and promote recovery due to his increasing and changing medication schedule related to immobility and decreased cognition.”

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4.  Teaching and Training:

This references activities that require skilled nursing or skilled rehabilitation personnel to teach a patient and/or family member how to manage the patient’s treatment regimen. 

Topics to document may include: 

  • colostomy care,
  • insulin administration,
  • prosthesis management,
  • catheter care,
  • G-tube feedings, I
  • IV access sites,
  • braces, splints and orthotics and
  • wound dressings and skin treatments. 

In these situations, the nurse may write: 

“This patient requires daily skilled nursing for teaching and training of self administration of insulin injections.”

If you have questions about Skilled Nursing Documentation, please contact Harmony Healthcare International by clicking here or calling our office at (800) 530-4413. 


Topics: Documentation

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