Long-Term Care Pocket Guide to Nursing Documentation

Make documentation less time-consuming and confusing with help from a pocket-sized guide from HCPro.

The Long-Term Care Pocket Guide to Nursing Documentation provides long-term care nurses with the most critical, need-to-know information about documentation. This pocket-sized guide contains all of the necessary components for reimbursement and regulatory requirements. It will reduce documentation errors, help documentation stand up to survey scrutiny and help create more lawsuit-proof documentation record.

With this guide, your staff will:

• Quickly access critical documentation information when they need it
• Understand how various items affect reimbursement and surveys
• Ensure that they are documenting correctly all the time
• Take advantage of plenty of charts, tips boxes, checklists, and an essential guide that they will use every day
• Answer documentation questions quickly and prevent potential survey tags

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

Want a pocket guide for every nurse in your facility? Call 800/650-6787 and ask about bulk discounts for 10 or more copies.

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