Harmony Healthcare Blog

Skilled Nursing Documentation (Part 2): Assessments vs Conclusion Statements

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Wed, May 25, 2016

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Edited by Kris Mastrangelo

Nursing DocumentationIt is not uncommon for Harmony Healthcare International (HHI) audits to reveal documentation reflecting “conclusion statements” rather than “skilled assessments.” 

For example, the note might document “no signs or symptoms of respiratory distress” without the details of how the nurse made that determination.  

The following examples depict frequently seen conclusion statements and offers suggestions for refinement utilizing “skilled assessment terminology” while incorporating the standard Medicare Coverage pillars (See Part 1: The Four Pillars).

 Patient Number 1
(Inherent Complexity) 

Common Conclusion Statement:  

“No signs or symptoms of cardiovascular distress.” 

Refined Skilled Assessment:  

“This patient requires daily skilled nursing due to the inherent complexity of IV Medication administration secondary to the patient’s recent MI.  164/73, p99, rr20, weight 147.  1+ lower extremity edema noted, encouraged to elevate legs.  No complaints or signs of chest pain.  No s/s bleeding secondary to Coumadin Therapy.  O2 sat 96% on RA, LSC, HOB elevated secondary to SOB lying flat.  Patient educated on importance of following a low salt diet. Daily skilled nursing required until this patients treatment regimen has essential stabilized.” 

Patient Number 2
(Observation and Assessment)

Common Conclusion Statement: 

“No signs or symptoms of hypo/hyperglycemia.”

Refined Skilled Assessment: 

This patient requires daily skilled nursing observation and assessment of signs and symptoms of exacerbation of hypo/hyperglycemia. a.m. BG 148.  No coverage needed.  Skin intact.  No trembling, vision changes, headaches, dizziness, or nausea noted.  Patient remains alert and oriented x 3.  Patient voiding without difficulty, no increased thirst noted. Weight 164.  Patient educated on importance of low sugar diet."

Patient Number 3
(Management of Care Plan)

Conclusion statement:  

“No signs or symptoms of UTI.” 

Refined Skilled Assessment: 

“This patient requires daily skilled nursing for overall management and evaluation of care plan to ensure medical safety and promote recovery due to his recent UTI, changing medication schedule, immobility and decreased cognition.T97.8°.  Alert and oriented x 3.  Continue Bactrim, no adverse reactions noted.  Fluids taken well, no c/o dysuria, urgency, abdominal pain, hematuria, or nausea.” 

Patient Number 4
(Teaching and Training)

Conclusion statement:

“No signs or symptoms of respiratory distress.”

Refined Skilled Assessment: 

“This patient requires daily skilled nursing for teaching and training of self spirometry.  Cough noted, baseline crackles, wheezing noted, SOB lying flat, at rest, and on exertion, RR20, O2 sat 94% on 3L O2 via NC, 88% on RA.  No cyanosis/pallor.  Nebulizer treatment administered as ordered, post-neb assessment with decreased wheezing, decreased SOB, decreased use of accessory muscles, O2 sat 98% on 3L.  Fluids encouraged, taken well.”

Nursing Documentation will always be a work in progress. Ongoing medical record reviews provide every organization with continuous feedback on nuggets for improvement.  Harmony Healthcare International (HHI) encourages facilities to always look for the areas of improvement to make your facility a better place for the senior population live, improve, and transition. 

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


Tags: Skilled Nursing Documentation

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