Long-Term Care Pocket Guide To
Long-Term CareLong-Term CarePocket Guide toNursingDocumentation
ContentsSection I: The medical mItemI-15:I-16:I-17:I-18:I-19:I-20:I-21:I-22:. . . . . . . . . . . . . . .1The medical record . . . . . . . . . . . . . . . . . .Resident’s name and medical record numberMonth, 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 consistent with the rest of themedical 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 . . . . . . . .3. .5. .34.35.36
6:I-27:I-28:I-29:I-30: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 . . . . . . . . . . .Item I-31: Documenting care provided by another nurseItem I-32: Resident amendments to the medical record . .Item I-33: Proper error correction procedure . . . . . . . . .37.38.39.41.42.43.44.48.50.52.55Section II: Resident assessments and otherrelated documents . . . . . . . . . . . . . . . . . . . . . 0:II-11:II-12: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 interestassessments (F248) . . . . . . . . . . . . . . .Item II-13: Social services (F250) . . . . . . . . . . . . .59.60.62.63.65.66.68.69.70.72.73. . . . . .74. . . . . .75
Item II-14: Mental and psychosocial functioning(F319, F320) . . . . . . . . . . . . . . . . . . . . . . . . .77Item II-15: Restorative/rehab nursing assessment (F317) . . .78Section III: Other types of medicaldocumentation . . . . . . . . . . . . . . . . . . . . . . . . . 79Item III-1:Item III-2:Item III-3:Item III-4:Item III-5:Item III-6:Item III-7:Item III-8:Item III-9:Item III-10:Item III-11:Item I-16:III-17:Pharmacy drug review (F428) . . . . . . . . . . . . .81Antipsychotic drug therapy (F330) . . . . . . . . . .82Dose reduction schedules anddocumentation (F331) . . . . . . . . . . . . . . . . . . .83Medication and treatment records . . . . . . . . . .85Flow sheets/flow records . . . . . . . . . . . . . . . . .86Lab and special reports (F504, F505,F511, F510) . . . . . . . . . . . . . . . . . . . . . . . . .87Consents, acknowledgements, and notices . . . .89Consent, notice, and authorization touse/release medical records (F164) . . . . . . . . .90Notice of bed-hold policy and readmission (F205) . .91Notice of legal rights and services (F156) . . . . .92Notice before transfer (F203) . . . . . . . . . . . . . .93Notice prior to change of room orroommate (F247) . . . . . . . . . . . . . . . . . . . . . .94Advance directives (F155-156) . . . . . . . . . . . .95DNR order v. advance directives . . . . . . . . . . .96Discharge documentation (F202) . . . . . . . . . . .97Discharge summary (F283, F284) . . . . . . . . . .98Physician’s discharge summary v.discharge record . . . . . . . . . . . . . . . . . . . . .100
Section IV: Physician documentation . . . . . . . .101Item IV-1: Physician progress notes (F386) . . . . . . . . . . .103Item IV-2: Dictated progress notes . . . . . . . . . . . . . . . . .105Item IV-3: Nurse practitioner and physician assistantdocumentation . . . . . . . . . . . . . . . . . . . . . . .106Item IV-4: History and physical . . . . . . . . . . . . . . . . . . .107Item IV-5: Other professional consultation records/notes .108Item IV-6: Documenting the resident’s diagnoses . . . . . . .109Item IV-7: Physician orders . . . . . . . . . . . . . . . . . . . . . .112Item IV-8: Content of an order . . . . . . . . . . . . . . . . . . .113Item IV-9: Physician order recaps/renewals . . . . . . . . . .116Item IV-10: Fax orders (F386) . . . . . . . . . . . . . . . . . . . . .117Item IV-11: Standing-order policies . . . . . . . . . . . . . . . . .118Item IV-12: Authentication/obtaining signatures . . . . . . . .119Item IV-13: Transcription of orders and noting orders . . . .120Item IV-14: Contacting the physician to obtain an order . .121Item IV-15: Discontinuing an order when a new orderis obtained . . . . . . . . . . . . . . . . . . . . . . . . . .123Item IV-16: Updating/changing physician order recaps/renewals after they have been signed . . . . . . .124Item IV-17: Processing physician orders after hospitalization”resume previous orders” . . . . . . . . . . . . . . . . .125Item IV-18: Verification of hospital orders withattending physician . . . . . . . . . . . . . . . . . . . .126Item IV-19: Accepting orders from an NP or PA . . . . . . . .127Item IV-20: Accepting orders from specialistsor consultants . . . . . . . . . . . . . . . . . . . . . . . .128
Section IThe MedicalRecord
Item I-1: The medical record describing the services provided to the resident providing evidence that the care was necessary documenting the resident’s response to the care andchanges made to the plan of care identifying the standards by which care was deliveredSection I: The Medical RecordItem I-1: The medical recordThe resident’s medical record (commonly referred to as the“chart”) is used by all members of the healthcare team tocommunicate the resident’s progress and the current treatment. It provides a record of the resident’s health status,including observations, measurements, history, and prognosis, and serves as the legal document describing the healthcare services provided to the resident. The chart also is usedto determine the appropriateness and quality of care byIThe chart also provides supporting documentation for the reimbursement ofservices provided to the resident a source of data for clinical, health services, andoutcomes research, as well as public health purposes a major resource for healthcare practitioner education, the legal business record for a healthcare organization, and support for business decision-making3
Anyone who documents in the medical record shouldbe credentialed/have the authority and right to document as defined by facility policy.ISection I: The Medical RecordItem I-1: The medical recordDocumentation Do’s:Who charts inthe medical record?4
Item I-2: Resident’s name andmedical record numberWhen double-sided forms are used, the resident’s nameand medical record number must be on both sides becauseinformation is often copied and must be kept with the correct data for that resident.Section I: The Medical RecordItem I-2: Resident’s name and medical record numberEvery page of the medical record or computerized recordscreen must show the resident’s name and medical recordnumber. This includes both sides of the pages, every shingled form, computerized print out, etc.I5
Item I-3: Month, day, year, timeSection I: The Medical RecordItem I-3: Month, day, year, timeInclude the month, day, year, and time of each event orobservation with every medical record entry. Include thetime in all types of narrative notes even though it may notseem important to the type of entry.I6
Documentation don’ts:Time blocksFor certain types of flow sheets, such as a treatmentrecord, recording time as a block could be acceptable. For example, a treatment that can be deliveredany time during a shift could have a block of time identified on the treatment record with staff signing that theydelivered the treatment during that shift.Section I: The Medical RecordItem I-3: Month, day, year, timeDo not chart time as a block (e.g., 7–3), especially fornarrative notes. Narrative documentation should reflectthe actual time the entry was made.I7
IChart entries as soon as possible after an event or observation is made.Section I: The Medical RecordItem I-3: Month, day, year, timeIndicate the date and time of completion as well as whohas completed each section of assessment forms wheremultiple individuals are completing the form.8
Do not make entries in advance. Pre-dating or backdating an entry is both unethical and illegal. Entriesmust be dated with the actual date and time the entryis made.ISection I: The Medical RecordItem I-3: Month, day, year, timeDocumentation don’ts:Advanced entries andpre- and back-datingIf it is necessary to summarize events that occurred overa period of time (such as a shift), the notation shouldindicate the actual time the entry was made with the narrative documentation identifying the time at which therelevant events occurred.9
Item I-4: SignaturesWhat to includeAt minimum, the signature should include the first initial,last name, and title/credential.If there are two people with the same first initial and lastname, both must use their full signatures (and/or middleinitial, if applicable).Section I: The Medical RecordItem I-4: SignaturesEvery entry in the medical record must be signed by theperson making the entry. This includes all types of entries,such as narrative/progress notes, assessments, flow sheets,orders, etc., whether in paper or electronic format.ICountersignaturesCountersignatures should be used as required by statelaw (e.g., a graduate nurse who is not licensed, a therapyassistant, etc.) The person who is making the countersignature must be qualified to countersign. For example,a licensed nurse who does not have the authority to supervise should not be countersigning an entry for a graduatenurse who is not yet licensed.10
ISection I: The Medical RecordItem I-4: SignaturesFederal regulations for long-term care (LTC) do not requirecountersignatures for nurse practitioners and physicianassistants, but state licensure and professional practice regulations may govern them.11
Item I-5: InitialsEach person who documents with initials in the medicalrecord must have a corresponding full signature on record.Three methods that may be used include the following: A signature legend can be included on the actualform where the initials are used. A separate master signature legend form can be keptwith staff initials and signatures for each resident’srecord. The facility may keep one facility master signaturelegend. A copy of the legend will be made at thetime of discharge and placed in the resident record.Section I: The Medical RecordItem I-5: InitialsAny time a facility chooses to use initials in any part of therecord for authentication of an entry, there has to be corresponding full identification of the initials on the sameform or on a signature legend.IWhen to use initialsInitials can be used to authenticate entries, such as flow sheets,medication records, or treatment records, but should not beused in such entries as narrative notes or assessments.12
Documentation don’ts:When not to use initialsSection I: The Medical RecordItem I-5: InitialsNever use initials where a signature is required bylaw (e.g., on the MDS).I13
Item I-6: Rubber stamp signaturesFrom a reimbursement perspective, some fiscal intermediaries (FI) have local policies prohibiting the use of rubberstamp signatures in the medical record even though federalregulation allows for their use.Section I: The Medical RecordItem I-6: Rubber stamp signaturesIf allowed by your state and reimbursement regulations,rubber stamp signatures are acceptable. Federal regulations for nursing facilities allow for the use of rubber stampsignatures by physicians provided that the facility authorizes their use and has a statement on file indicating that thephysician is the owner of the stamp and attested that theywill be the only one using the signature stamp.IFacility policies should indicate whether rubber stampsignatures are acceptable and define the circumstancesfor their use after review of state regulations and payerpolicies.14
Item I-7: Fax signaturesThe original signature should be retrievable when faxdocument/signatures are included in the medical record.Section I: The Medical RecordItem I-7: Fax signaturesRules about fax signatures depend on state, federal, andreimbursement regulations. Federal regulations for nursingfacilities do not prohibit the use of fax signatures. Unlessspecifically prohibited by state regulations or facility policy,fax signatures are acceptable.I15
Item I-8: Faxed recordsFor example, if a thermal paper fax paper is used, a copyof it must be made for filing in the medical record since theprint on thermal paper fades over time.The medical record should contain original documentswhenever possible. There are times when it is acceptableto have copies of records and signatures, particularlywhen records are sent from another healthcare facility orprovider.Section I: The Medical RecordItem I-8: Faxed recordsIf fax records are maintained in the medical record, thefacility must be sure that the record will maintain itsintegrity over time.IIf there is a question about the permanency of the paper(e.g., NCR, or carbon paper) when the carbon paper isthe permanent entry, it needs to be photocopied.At times carbon copies of documents (e.g., telephoneorders) may be used on a temporary basis and the originalwill replace the carbon when it is received.16
Item I-9: Legible, ink entriesBlack or dark blue ink reproduces especially well onmicrofilm.Section I: The Medical RecordItem I-9: Legible, ink entriesAll entries in the medical record, regardless of form or format, must be in ink so that changes are noticeable and therecord is permanent.I17
Documentation don’ts:Colored ink and pencilSection I: The Medical RecordItem I-9: Legible, ink entriesNo other colored ink should be used in the event thatany part of the record needs to be copied. The inkshould be permanent (no erasable or water-soluble inkshould be used). Never use a pencil to document inthe medical record.I18
If an entry cannot be read, the author should rewrite theentry on the next available line, define what the entry isfor, referring back to the original documentation, and legibly rewrite the entry. For example, start with “Clarifiedentry of (date)”, then rewrite entry, date, and sign. Therewritten entry must be the same as the original.ISection I: The Medical RecordItem I-9: Legible, ink entriesLegibilityAll entries in the medical record must be legible. Illegibledocumentation can put the resident at risk. Readable documentation assists other caregivers and helps to ensurecontinuation of the resident’s plan of care.19
Item I-10: Do not skip linesA new form should not be started until all previous linesare filled. If a new sheet was started, the lines availableon the previous page must be crossed off.Section I: The Medical RecordItem I-10: Do not skip linesDocument entries on the next available space—do not skiplines or leave blanks. There must be a continuous flowof information without gaps or extra space betweendocumentation.I20
Documentation do’s:Out-of-order entriesSection I: The Medical RecordItem I-10: Do not skip linesIf an entry is made out of chronological order it shouldbe documented as a late entry.I21
Item I-11: All fields/blocksare to be filledIf a field is not applicable, an entry like “N/A” shouldbe made to show that the question was reviewed andanswered.Fields or blocks left blank may be suspect to tampering orback-dating after the document has been completed andsigned. If the documentation will be reported by exception(e.g., documenting only on shifts where a behavior occurs),there should be a statement on the form indicating howcharting will be completed.Section I: The Medical RecordItem I-11: All fields/blocks are to be filledOn assessments, flow sheets, and on checklist documents,some of the questions or fields may not be applicable tothe resident. All fields or blocks should have some entrymade whether or not it applies to the resident.I22
Item I-12: Language of themedical recordSection I: The Medical RecordItem I-12: Language of the medical recordWhen making entries in the medical record, use language that is specific rather than vague or generalized.I23
Do not speculate when documenting – the recordshould only reflect factual information (what is known,not what is thought or presumed) and be written usingfactual statements. Personal opinions should not beused when charting.Document what can be seen, heard, touched, and smelled.Describe signs and symptoms, use quotation marks toquote the resident, and document the resident’s responseto care.ISection I: The Medical RecordItem I-12: Language of the medical recordDocumentation don’ts:Speculation andpersonal opinionsDocument all facts and pertinent information related to anevent, course of treatment, resident condition, response tocare, and deviation from standard treatment (including thereason for it). Make sure the entry is complete and contains all significant information. If the original entry isincomplete, follow guidelines for making a late entry,addendum, or clarification.24
Item I-13: AcceptableabbreviationsSection I: The Medical RecordItem I-13: Acceptable abbreviationsEvery facility should set a standard for acceptable abbreviations to be used in the medical record. Only those abbreviations approved by the facility should be used in themedical record. When there is more than one meaning foran approved abbreviation, one meaning should be chosenor the context should be identified in which the abbreviation is to be used.I25
Item I-14: Entries consistent withthe rest of the medical record concurrent entries other parts of the medical record—the assessments,care plan, physician’s orders, medication and treatment records, etc. other facility documents—incident reports, 24-hourreports, nursing service shift reports, etc.Ongoing treatments and conditions (feeding tube, vent,trach, catheter, etc.) should be noted as continuing. Avoidrepetitive (copycat or parrot) charting. The current entryshould document current observations, outcomes/progress.Section I: The Medical RecordItem I-14: Entries consistent with the rest of the medical recordAll entries should be consistent withI26
If an entry is made that contradicts previous documentation, the new entry should elaborate or explain whythere is a contraindication or why there has been achange.ISe
tions for nursing facilities allow for the use of rubber stamp signatures by physicians provided that the facility authoriz-es their use and has a statement on file indicating that the physician is the owner of the stamp and attested that they will be the only one using the signature stamp. From a reimbursement perspective, some fiscal intermedi-
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into long-term health care benefit plans. Conversely, Medicaid expenses on long-term health care services for residents may be offset by similar amounts (as aforementioned) annually. This is about 5.07-5.78 percent of the Medicaid long-term care appropriations for Nursing Home Careor 2.99-3.40 percent of the total Medicaid Long Term
