Charting / Documentation Guide
Nursing documentation should be clear, timely, accurate, reflective of observations, permanent and legible. This is a guide and not a complete list. Always follow policies in place at your facility.
Medicare Documentation
• Must reflect need/reason for skilled care
• Must reflect Standard of Care
• Describe intervention(s)
• Describe resident’s response to intervention(s)
• Daily evaluation of progress or lack of progress
• Resident response to skilled therapy
• ADL function
• Changes in condition
• Change Care Plan ASAP after change in condition
• Notification to MD and family

Respiratory/Pneumonia
Medicare Documentation
• Must reflect need/reason for skilled care
• Daily vital signs
• Daily and PRN O2 sat level
• Daily and PRN lung sounds
• SOB with exertion, when sitting at rest or when lying flat
• Resident’s response to interventions and skilled therapy
• Progress or lack of progress
• Change in condition
• Change Care Plan ASAP after condition change
• Notification to MD and family

Bladder and Bowel
• Indicate status: always continent, occasionally incontinent, frequent- ly incontinent, always incontinent
• Indicate if has catheter (indwell- ing or condom, intermittent), uri- nary ostomy, or no urine output
• Toileting program in progress or attempted and outcome
• Constipation? Which interventions used, and results?

Anticoagulant Therapy
Medicare Documentation
• Must reflect need/reason for skilled care
• Daily vital signs
• Monitor for bleeding, bruises
• Monitor lab values: Be sure PT/INR drawn per physician order and reported to MD
• Monitor sudden dyspnea, chest pain, temp or color change in extremities

ADLs
• How does resident perform? – Bed mobility – Transfers – Ambulation – Dressing – Eating – Toileting