MEDICARE CHARTING GUIDELINES

Resident Name: ______________________________ Date of Admission: ___/___/___

Admitting Dx (Main:_________________________________________________________________
!t"e# Dx:___________________________________________________________________________
Guidelines:
1. Chart Q Day.
2. Use this guideline to focus your charting.
3. Guideline to be completed by Medicare urse! Unit Manager! or other ursing "uper#isor.
$%&"' ('$ ")*++*G ' M%D*C&$%:
,hysical -herapy 'ccupational -herapy "peech -herapy $espiratory -herapy Unstable *DDM *n.ections /*M only0 e1 G2-ube (eeding
DecubitusUlceration 3 "tage*** "tage *4 5 Multi2"tage ** 6 'ther 7ounds /i.e. s8p "urgical 18complications0 *.4. -herapy "traight Catheteri9ation
Colostomy8*leostomy Care Medication &d.ustment Dehydration8Malnutrition *solation ,atient -eaching8ursing $ehab
Medically Unstable Condition Cardio#ascular Compromise Gastrointestinal Complications Circulation ,roblems :emodialysis /18 complications0

T$%E !& S'ILLED SER(ICE T$%E !& S'ILLED SER(ICE T$%E !& S'ILLED SER(ICE
Physical, Occupational Therapy
Describe exactly how the resident performs
ADLS.
Describe the amount of assistance provided
Describe how the resident accomplishes the
following:
Bed Mobility **
Transferring **
Ambulates
Dresses Self
Eats (Including !"ubes#$$
Toilet Use (Including %ost!&se
'ygiene#$$
%ersonal 'ygiene and (athing
D)S*+I() S,ILL)D -&+SI-
I-")+.)-"I/-S &S)D "/ */0%)-SA")
1/+ ADL D)1I*I"S
$$ Indicates one of the 4 LTE LO!! "L!
#hich assign an "L Inde$ !core for %U&
calculation.
!peech Therapy
Describe )xactly how the resident
communicates and ma2es needs 2nown.
Describe s2illed nursing interventions used to
compensate for speech deficits.
Describe residents ability to swallow foods
and s2illed nursing interventions used to
compensate for impaired swallowing abilities.
%espiratory Therapy ' I(paired
%espiratory !tatus
Describe s2illed trach care rendered
Describe accurately breath sounds over all
lung aspects (i.e. whee3es4 rales4 ronchi#.
Describe respiratory rate4 rhythm and 5uality.
Describe the effectiveness of any respiratory
treatments given (i.e. -ebuli3ers4 *hest %"4
/ther +espiratory 0edications4 /xygen4 etc#
Describe residents comfort level as r6t
respiratory status.
Describe any changes in L/*4 anxiety or
other mental status changes.
Describe each incident of suctioning and any
other invasive techni5ues.
Describe resident7s overall condition as r6t
respiratory status and any s2illed nursing
interventions used to aid in comfort and
improve overall status.
Unstable I""M
Describe amount of order changes and
physician visits (+e5uires in the past 89 days
: order changes and : 0D visits /+ 9 order
changes#
Describe any s2illed nursing interventions
used to teach resident self administration.
Describe outcome of resident teachings.
Describe any signs and symptoms associated
with fluctuating blood sugar levels.
I)M) or I)*) Medication d(inistration
Describe nature of medication used (include
reason for use# and nursing s2ills and
observations used in administration of
medication.
Describe effectiveness of medication and any
side effects observed.
Describe how resident tolerated such therapy
(i.e. I. infiltration4 fluid volume overload4 pain4
phlebitis4 etc#
+e# &astrosto(y Tube ,eeding
Describe amount of fluids6feedings delivered
Describe resident7s ability to communicate
and ma2e needs 2nown to staff
Describe how resident tolerated tube feeding
; specifically any adverse effects to feeding
such as diarrhea4 abdominal distension4
*ardiac symptoms4 abnormal lung sounds.
Describe type of ostomy care rendered
around !"ube site and condition of site.
Describe clinical necessity for !"ube6<!"ube
"ecubitus Ulceration (Stage III or I. or
0ulti! II7s#
Describe condition of wound
Describe response to current treatments
Describe nursing interventions used to
prevent further ulcer development
Describe s2illed nursing interventions used to
aid in wound healing
Describe consumption amounts of meals and
fluids provided.
Describe overall s2in condition including poor
s2in turgor4 bruises4 rashes4 cyanosis4
redness4 edema or other abnormaility.
Document any interventions implemented r6t
abnormal lab values (i.e. low '='4 low serum
albumin4 low 1e> levels4 etc#
Describe dietary interventions implemented
such as increased vitamin * and protein foods
offered.
At least 5 wee24 describe in detail wound
measurements4 locations and response to
treatments.
!urgical -ounds or Open Lesions (does
not include rashes4 ulcers and cuts#
Describe location and nature of wound.
Describe any pain r6t to surgical wound and
interventions used to combat pain.
Describe nursing interventions and
observations r6t surgical wound healing
process
Describe any drainage4 areas of increased
errythema4 or warmth.
Describe response to any treatments ordered.
At least 5 wee2 describe in detail wound
healing process and response to tx.
!traight .atheteri/ation ' &U
.o(plications
Describe nature of resident7s condition that
warrants the use of straight catheteri3ation
techni5ues.
Describe use of sterile techni5ue during
catheter administration.
Describe any resident teaching r6t catheter
use.
Describe any clinical conditions present that
re5uire s2illed nursing observation (such as
fre5uency4 dysuria4 indicators of &"I4 etc#
+ursing %ehabilitation (As applicable#
Describe outcome of Insulin In?ection instruction
Describe outcome of colostomy 6 Ileostomy care training
Describe outcome of Supra!pubic catheter care training
Describe outcome of self wound care training
Describe outcome of medication self!administration training
Describe outcome of stump care training
Describe outcome of bowel and bladder training
Describe outcome of any s2illed teaching provided to resident
IMPO%T+T +OTE %E&%"I+& ,%&ILE ME"I.L .O+"ITIO+ %E!I"E+T!
T0T M1 ,LL I+TO T0E !E, !!, ., I, B, and P .TE&O%IE!2
'*1A has identified that the observation and evaluation of care plans are no longer
acceptable administrative reasons for s2illed coverage. 'owever4 in proxy4 the
following criteria will be used to determine medical fragility:
I+ T0E P!T 34 "1! T0E %E!I"E+T MU!T 0*E EIT0E%2
8. 4 Physician *isits +" 4 Physician Order .hanges /+
:. 3 Physician *isit +" 4 Physician Order .hanges
MEDICALLY COMPLEX or UNSTABLE CONDITIONS
.erebral Palsy or Multiple !clerosis or 5uadriplegia Present ; Describe ADL status as well as s2illed nursing interventions used to assist resident
overcome ADL compromise (see above section#
,e6er Present 74)4 degrees higher than baseline te(perature8 ; Describe interventions to control and or monitor fever.
,e6er and *o(iting Present ; Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation
,e6er and -eight Loss Present ; Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation
,e6er and Tube ,eeding -ith 0igh Enteral Inta9e ! Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation
,e6er and "$ of Pneu(onia present ! Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation
,e6er and "ehydration Present ! Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation
.o(atose ! Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation
!eptice(ia ! Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation
Burns ! Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation of burn site4 response to treatment and pain
management.
End !tage "isease ! Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation as well as comfort measures
"ehydration ! Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation as well as measures to correct dehydration.
0e(iplegia'Paresis +" "L dependence ! Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation as well as s2illed
interventions to assist resident cope with ADL dependence.
Internal Bleeding2 Describe s2illed nursing interventions used to maintain homeostasis and s2illed observation r6t anemia (i.e. fatigue4 s2in color4 signs of
shoc24 etc#
.he(otherapy2 Describe in detail response to chemotherapy treatment and s2illed nursing observation r6t discomfort and general malaise associated with
chemo treatment.
"ialysis2 Describe s2illed nursing interventions used to maintain homeostasis and s2illed observations r6t signs of hyper2alemia (monitor ,> levels#4 inta2e
and output (as necessary#4 monitor for edema and respiratory compromise4 '=' and signs of infection.
Transfusions2 Describe s2illed nursing interventions and s2illed observation r6t transfusions including renal failure4 increased anxiety levels4 dyspnea4
severe headache4 severe pain in nec24 severe chest pain4 and severe lumbar pain4 evidence of shoc24 oliguria4 fever4 urticaria4 edema4 whee3ing4 di33iness4
<.D4.
O$ygen Therapy2 Any use of oxygen in the past 89 days re5uires documentation of respiratory status (See previous section#
%adiation Therapy2 Describe s2illed nursing interventions and s2illed observation r6t radiation treatment:
-eurologic: "remors4 *onvulsions4 Ataxia4 Anxiety4 *onfusion
I: -ausea4 .omiting and Diarrhea4 Dehydration
*.: *irculatory *ompromise6*ollapse4 Anemia
eneral: %ain4 S2in Irritation4 S2in )xposure to )lements
Infection on ,oot O% Open Lesion on ,oot2 Describe all s2illed nursing interventions r6t treatment of foot ulcer6lesion and interventions r6t prevention of
further foot complications.
Unstable +eurological !tatus2 Describe s2illed nursing interventions and s2illed observation including Level of *onsciousness4 %upilary +eactions4
0uscular @ea2ness4 Sei3ure Activity.
Unstable &astrointestinal !tatus2 Describe s2illed nursing interventions and s2illed observation r6t -ausea4 .omiting4 Diarrhea4 (owel Sounds4 Distntion4
Sudden @eight Loss4 %ain4 and monitoring for I bleed (hemocult#
Unstable .ardio6ascular !tatus2 Describe s2illed nursing interventions and s2illed observation r6t 'eart +ate and +hythm4 )dema4 *hest %ain4 Lung
Sounds4 (*ardiac# 0edication &se4 +apid @eight ain4 %edal %ulses4 )xtremity S2in *olor6@armth4 *apillary +efil4 %ain6-umbness6"ingling.
Unstable .ondition %e:uiring !9illed Medication d(inistration2 Including monitoring for adverse side effects4 electrolyte imbalances4 internal bleeding
(coumadin6heparin#4 antibiotic responses in acute conditions4 steroid therapy4 chemotherapy (as above#4 pain management and psychotropic medication
ad?ustments.
.O&+ITI*E +" BE0*IO%L !1MPTOMOLO&1 (enerally D/ -/" enable 0edicare (enefits but must be accurately recorded as they do affect +&!III Scoring#
.ogniti6e Loss2 Describe severity of cognitive loss and accurately describe current level of orientation (i.e. person4 place4 time# as well as area of deficit (i.e.
short term or long term memory affected#
!igns of "epression2 Describe accurately any signs of depression displayed to include but not limited to: -egative statements made4 repetitive 5uestions4
calling out4 persistent anger4 self!depreciation4 unrealistic fears4 repetitive non!health related complaints4 unpleasant mood in morning4 insomnia or change in
usual sleep pattern4 sad6anxious appearance4 crying6tearfulness4 repetitive physical movements4 withdrawn from activities and social interaction.
Beha6ior !y(pto(s Present2 Describe s2illed nursing interventions to establish resident safety upon observance of the following behaviors: @andering
halls oblivious to safety4 verbally abusive towards others4 physically abusive towards others4 socially inappropriate behavior or resistance to care.
0allucinations or "elusions Present2 Describe all s2illed nursing interventions implemented to assist resident cope with any hallucination or delusions and
include s2illed nursing observations regarding same.
; 2<<< &+"&