Documentation is one of the most time-consuming — and confusing — tasks for the nurses in your facility. But this documentation is critically tied to your residents' quality of care, your documentation, and most importantly — your reimbursement.
Introducing the Long-Term Care Pocket Guide to Nursing Documentation. This pocket guide will provide long-term care nurses with the most critical, need-to-know information about documentation. With this guide, you can feel confident that your nurses' documentation contains all of the necessary components for reimbursement and regulatory requirements.
This valuable pocket guide can be purchased individually, or in packs of 10. You SAVE $200 when you purchase 10 copies!
Long-Term Care Pocket Guide to Nursing Documentation will help speed up the documentation process, saving your nurses valuable time — and saving you money. It will reduce documentation errors, help documentation stand up to survey scrutiny and help create more lawsuit-proof documentation record.
With the all the tools and tips you need packed into this conveniently sized pocket guide, your nurses will have an "advisor" on hand at all times. With this guide, your staff will:
- quickly access critical documentation information
- understand how various items affect reimbursement and surveys
- ensure that they are documenting correctly all the time
- have easy access to the most essential — and often erroneously documented-information
- take advantage of plenty of charts, tips boxes, checklists, and an essential guide that they will use every day
- comprehensive information and highlighted critical concepts that will help ensure proper documentation — and reimbursement — in virtually every situation
- answer documentation questions quickly and prevent potential survey tags!
Long-Term Care Pocket Guide to Nursing Documentation will save your staff time—and save your facility money.
Take a look at the tools and information packed into this 125-page pocket-sized tool!
Section I: The medical record
The medical record ♦ Resident's name and medical record number ♦ Month, day, year, time ♦ Signatures ♦ Initials ♦ Rubber stamp signatures ♦ Fax signatures ♦ Faxed records ♦ Legible, ink entries ♦ Do not skip lines ♦ All fields/blocks are to be filled ♦ Language of the medical record ♦ Acceptable abbreviations ♦ Entries should be consistent with the rest of the medical record ♦ Change in the resident's condition ♦ Informed consent ♦ Note/discharge summary ♦ Notification ♦ Charge nurse responsibilities ♦ Incident reporting ♦ Factual and objective information ♦ Narrative charting and summaries ♦ Admission/readmission narrative note ♦ Content of narrative charting ♦ Monthly summary charting ♦ Medicare documentation ♦ Skilled nursing/therapy charting ♦ Therapy treatment time ♦ Omissions in documentation ♦ Omissions on medication/treatment records, graphic, and other flow sheets ♦ Documenting care provided by another nurse ♦ Resident amendments to their medical record ♦ Proper error correction procedure
Section II: Resident assessments and other related documents
♦ Admission record ♦ Assessments ♦ Types of assessments ♦ Preadmission assessment ♦ Admission assessment ♦ Fall assessment (F324) ♦ Skin assessment (F314) ♦ Bowel and bladder assessment (F316) ♦ Physical restraint assessment (F221) ♦ Self-administration of medication (F176) ♦ Nutrition assessment (F325) ♦ Activities/recreation/leisure interest assessments (F248) ♦ Social services (F250) ♦ Mental and psychosocial functioning (F319, F320) ♦ Restorative/rehab nursing assessment (F317)
Section III: Drug therapy, medication/treatment records, flow sheets/records, lab and special reports, consents, acknowledgements and notices, advance directives, and discharge/transfer
♦ Pharmacy drug review (F428) ♦ Antipsychotic drug therapy (F330) ♦ Dose reduction schedules and documentation (F331) ♦ Medication and treatment records ♦ Flow sheets/flow records ♦ Lab and special reports (F504, F505, F511, F510) ♦ Consents, acknowledgements, and notices ♦ Consent, notice, and authorization to use/release medical records (F164) ♦ Notice of bed-hold policy and readmission (F205) ♦ Notice of legal rights and services (F156) ♦ Notice before transfer (F203) ♦ Notice prior to change of room or roommate (F247) ♦ Advance directives (F155-156) ♦ DNR order vs. advance directives ♦ Discharge documentation (F202) ♦ Discharge summary (F283, F284) ♦ Physician's discharge summary vs. discharge record
Section IV: Physician documentation
♦ Physician progress notes (F386) ♦ Dictated progress notes ♦ Nurse practitioner and physician assistant documentation ♦ History and physical ♦ Other professional consultation records/notes ♦ Documenting the resident's diagnoses ♦ Physician orders ♦ Content of an order ♦ Physician order recaps/renewals ♦ Fax orders (F386) ♦ Standing order policies ♦ Authentication/obtaining signatures ♦ Transcription of orders and noting orders ♦ Contacting the physician to obtain an order ♦ Discontinuing an order when a new order is obtained ♦ Updating/changing physician order recaps/renewals after they have been signed ♦ Processing physician orders after hospitalization ♦ Verification of hospital orders with attending physician ♦ Accepting orders from a nurse practitioner or physician assistant ♦ Accepting orders from specialists or consultants
The Long-Term Care Pocket Guide to Nursing Documentation is the only documentation-specific tool that your nurses can use to quickly break down coding and documentation complexity. Take the confusion out of documentation; pass your surveys with flying colors, and collect the dollars that you've earned!
Want a pocket guide for every nurse in your facility? The more copies of Long-Term Care Pocket Guide to Nursing Documentation you buy, the more you save! Buy 10 copies and SAVE $200!
Save money when you purchase multiple copies! Ask your customer service representative about money-saving
discounts and bulk orders. Call toll free 800-650-6787 or e-mail
customerservice@hcpro.com.
