MEDICARE CHARTING GUIDELINES
Resident Name: ______________________________ Date of Admission: ___/___/___
Admitting Dx (Main):_________________________________________________________________
Other Dx:___________________________________________________________________________
Guidelines:
1. Chart Q Day.
2. Use this guideline to focus your charting.
3. Guideline to be completed by Medicare Nurse, Unit Manager, or other Nursing Supervisor.
REASON FOR SKILLING ON MEDICARE:
Physical Therapy Occupational Therapy Speech Therapy Respiratory Therapy Unstable IDDM Injections (IM only) New G-Tube Feeding
DecubitusUlceration { StageIII Stage IV B Multi-Stage II } Other Wounds (i.e. s/p Surgical w/complications) I.V. Therapy Straight Catheterization
Colostomy/Ileostomy Care Medication Adjustment Dehydration/Malnutrition Isolation Patient Teaching/Nursing Rehab
Medically Unstable Condition Cardiovascular Compromise Gastrointestinal Complications Circulation Problems Hemodialysis (w/ complications)
TYPE OF SKILLED SERVICE TYPE OF SKILLED SERVICE TYPE OF SKILLED SERVICE
Physical, Occupational Therapy Speech Therapy Respiratory Therapy / Impaired
Describe exactly how the resident performs Describe Exactly how the resident Respiratory Status
ADLS. communicates and makes needs known. Describe skilled trach care rendered
Describe the amount of assistance provided Describe skilled nursing interventions used to Describe accurately breath sounds over all
Describe how the resident accomplishes the compensate for speech deficits. lung aspects (i.e. wheezes, rales, ronchi).
following: Describe residents ability to swallow foods Describe respiratory rate, rhythm and quality.
Bed Mobility ** and skilled nursing interventions used to Describe the effectiveness of any respiratory
Transferring ** compensate for impaired swallowing abilities. treatments given (i.e. Nebulizers, Chest PT,
Ambulates Other Respiratory Medications, Oxygen, etc)
Dresses Self Unstable IDDM Describe residents comfort level as r/t
Eats (Including G-Tubes)** Describe amount of order changes and respiratory status.
Toilet Use (Including Post-Use physician visits (Requires in the past 14 days Describe any changes in LOC, anxiety or
Hygiene)** 2 order changes and 2 MD visits OR 4 order other mental status changes.
Personal Hygiene and Bathing changes) Describe each incident of suctioning and any
DESCRIBE SKILLED NURSING Describe any skilled nursing interventions other invasive techniques.
INTERVENTIONS USED TO COMPENSATE used to teach resident self administration. Describe resident’s overall condition as r/t
FOR ADL DEFICITS Describe outcome of resident teachings. respiratory status and any skilled nursing
** Indicates one of the 4 LATE LOSS ADLS Describe any signs and symptoms associated interventions used to aid in comfort and
which assign an ADL Index Score for RUG with fluctuating blood sugar levels. improve overall status.
calculation.
I.M. or I.V. Medication Administration New Gastrostomy Tube Feeding Decubitus Ulceration (Stage III or IV or
Describe nature of medication used (include Describe amount of fluids/feedings delivered Multi- II’s)
reason for use) and nursing skills and Describe resident’s ability to communicate Describe condition of wound
observations used in administration of and make needs known to staff Describe response to current treatments
medication. Describe how resident tolerated tube feeding Describe nursing interventions used to
Describe effectiveness of medication and any – specifically any adverse effects to feeding prevent further ulcer development
side effects observed. such as diarrhea, abdominal distension, Describe skilled nursing interventions used to
Describe how resident tolerated such therapy Cardiac symptoms, abnormal lung sounds. aid in wound healing
(i.e. IV infiltration, fluid volume overload, pain, Describe type of ostomy care rendered Describe consumption amounts of meals and
phlebitis, etc) around G-Tube site and condition of site. fluids provided.
Describe clinical necessity for G-Tube/J-Tube Describe overall skin condition including poor
Surgical Wounds or Open Lesions (does Straight Catheterization / GU skin turgor, bruises, rashes, cyanosis,
not include rashes, ulcers and cuts) Complications redness, edema or other abnormaility.
Describe location and nature of wound. Describe nature of resident’s condition that Document any interventions implemented r/t
Describe any pain r/t to surgical wound and warrants the use of straight catheterization abnormal lab values (i.e. low H&H, low serum
interventions used to combat pain. techniques. albumin, low Fe+ levels, etc)
Describe nursing interventions and Describe use of sterile technique during Describe dietary interventions implemented
observations r/t surgical wound healing catheter administration. such as increased vitamin C and protein foods
process Describe any resident teaching r/t catheter offered.
Describe any drainage, areas of increased use. At least q week, describe in detail wound
errythema, or warmth. Describe any clinical conditions present that measurements, locations and response to
Describe response to any treatments ordered. require skilled nursing observation (such as treatments.
At least q week describe in detail wound frequency, dysuria, indicators of UTI, etc)
healing process and response to tx.
Nursing Rehabilitation (As applicable)
Describe outcome of Insulin Injection instruction IMPORTANT NOTE REGARDING FRAGILE MEDICAL CONDITION
Describe outcome of colostomy / Ileostomy care training RESIDENTS THAT MY FALL INTO THE SE, SS, C, I, B, and P CATEGORIES:
Describe outcome of Supra-pubic catheter care training
Describe outcome of self wound care training HCFA has identified that the observation and evaluation of care plans are no longer
Describe outcome of medication self-administration training acceptable administrative reasons for skilled coverage. However, in proxy, the
following criteria will be used to determine medical fragility:
Describe outcome of stump care training
Describe outcome of bowel and bladder training
IN THE PAST 14 DAYS THE RESIDENT MUST HAVE EITHER:
Describe outcome of any skilled teaching provided to resident 1. 2 Physician Visits AND 2 Physician Order Changes OR
2. 1 Physician Visit AND 4 Physician Order Changes
MEDICALLY COMPLEX or UNSTABLE CONDITIONS
Cerebral Palsy or Multiple Sclerosis or Quadriplegia Present – Describe ADL status as well as skilled nursing interventions used to assist resident
overcome ADL compromise (see above section)
Fever Present (2.4 degrees higher than baseline temperature) – Describe interventions to control and or monitor fever.
Fever and Vomiting Present – Describe skilled nursing interventions used to maintain homeostasis and skilled observation
Fever and Weight Loss Present – Describe skilled nursing interventions used to maintain homeostasis and skilled observation
Fever and Tube Feeding With High Enteral Intake - Describe skilled nursing interventions used to maintain homeostasis and skilled observation
Fever and Dx of Pneumonia present - Describe skilled nursing interventions used to maintain homeostasis and skilled observation
Fever and Dehydration Present - Describe skilled nursing interventions used to maintain homeostasis and skilled observation
Comatose - Describe skilled nursing interventions used to maintain homeostasis and skilled observation
Septicemia - Describe skilled nursing interventions used to maintain homeostasis and skilled observation
Burns - Describe skilled nursing interventions used to maintain homeostasis and skilled observation of burn site, response to treatment and pain
management.
End Stage Disease - Describe skilled nursing interventions used to maintain homeostasis and skilled observation as well as comfort measures
Dehydration - Describe skilled nursing interventions used to maintain homeostasis and skilled observation as well as measures to correct dehydration.
Hemiplegia/Paresis AND ADL dependence - Describe skilled nursing interventions used to maintain homeostasis and skilled observation as well as
skilled interventions to assist resident cope with ADL dependence.
Internal Bleeding: Describe skilled nursing interventions used to maintain homeostasis and skilled observation r/t anemia (i.e. fatigue, skin color, signs of
shock, etc)
Chemotherapy: Describe in detail response to chemotherapy treatment and skilled nursing observation r/t discomfort and general malaise associated with
chemo treatment.
Dialysis: Describe skilled nursing interventions used to maintain homeostasis and skilled observations r/t signs of hyperkalemia (monitor K+ levels), intake
and output (as necessary), monitor for edema and respiratory compromise, H&H and signs of infection.
Transfusions: Describe skilled nursing interventions and skilled observation r/t transfusions including renal failure, increased anxiety levels, dyspnea,
severe headache, severe pain in neck, severe chest pain, and severe lumbar pain, evidence of shock, oliguria, fever, urticaria, edema, wheezing, dizziness,
JVD,.
Oxygen Therapy: Any use of oxygen in the past 14 days requires documentation of respiratory status (See previous section)
Radiation Therapy: Describe skilled nursing interventions and skilled observation r/t radiation treatment:
Neurologic: Tremors, Convulsions, Ataxia, Anxiety, Confusion
GI: Nausea, Vomiting and Diarrhea, Dehydration
CV: Circulatory Compromise/Collapse, Anemia
General: Pain, Skin Irritation, Skin Exposure to Elements
Infection on Foot OR Open Lesion on Foot: Describe all skilled nursing interventions r/t treatment of foot ulcer/lesion and interventions r/t prevention of
further foot complications.
Unstable Neurological Status: Describe skilled nursing interventions and skilled observation including Level of Consciousness, Pupilary Reactions,
Muscular Weakness, Seizure Activity.
Unstable Gastrointestinal Status: Describe skilled nursing interventions and skilled observation r/t Nausea, Vomiting, Diarrhea, Bowel Sounds, Distntion,
Sudden Weight Loss, Pain, and monitoring for GI bleed (hemocult)
Unstable Cardiovascular Status: Describe skilled nursing interventions and skilled observation r/t Heart Rate and Rhythm, Edema, Chest Pain, Lung
Sounds, (Cardiac) Medication Use, Rapid Weight Gain, Pedal Pulses, Extremity Skin Color/Warmth, Capillary Refil, Pain/Numbness/Tingling.
Unstable Condition Requiring Skilled Medication Administration: Including monitoring for adverse side effects, electrolyte imbalances, internal
bleeding (coumadin/heparin), antibiotic responses in acute conditions, steroid therapy, chemotherapy (as above), pain management and psychotropic
medication adjustments.
COGNITIVE AND BEHAVIORAL SYMPTOMOLOGY (Generally DO NOT enable Medicare Benefits but must be accurately recorded as they do affect RUG-III Scoring)
Cognitive Loss: Describe severity of cognitive loss and accurately describe current level of orientation (i.e. person, place, time) as well as area of deficit (i.e.
short term or long term memory affected)
Signs of Depression: Describe accurately any signs of depression displayed to include but not limited to: Negative statements made, repetitive
questions, calling out, persistent anger, self-depreciation, unrealistic fears, repetitive non-health related complaints, unpleasant mood in morning, insomnia
or change in usual sleep pattern, sad/anxious appearance, crying/tearfulness, repetitive physical movements, withdrawn from activities and social
interaction.
Behavior Symptoms Present: Describe skilled nursing interventions to establish resident safety upon observance of the following behaviors: Wandering
halls oblivious to safety, verbally abusive towards others, physically abusive towards others, socially inappropriate behavior or resistance to care.
Hallucinations or Delusions Present: Describe all skilled nursing interventions implemented to assist resident cope with any hallucination or delusions
and include skilled nursing observations regarding same.
© 2000 ALSNA
