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 residents 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
Residents 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 and personal hygiene
How much staff support is
needed?
Independent
Set up help only
One person
Two + person physical assist
Activity does not occur
Document support needed for
ADLs over all shifts
Which interventions used to
compensate for ADL deficit:
i.e., walker, w/c, cane?

Change in Condition Requiring

a New Intervention
Time/Date
Change that has occurred
i.e., weight loss, pressure ulcer,
cognition,overall deterioration
Which ADLs are affected?
Which intervention applied?
Response to intervention?
Was MD or family notified?

Fracture Hip
Medicare Documentation
Must reflect need/reason for
skilled care
Daily vital signs including pain
ADL ability/assistance needed
(use MDS Language)
Monitor incision site
Indicate residents response to
therapy: pain, fatigue, etc.

Behavior
Assessment/Documentation
Date/Time
Location
Specific behavior
Who is around?
Any triggering event (loud noises,
new staff, providing care)?
How do symptoms interfere with
ADLs?
How does it interfere with care?
Rule out: hunger, toileting needs,
pain, boredom, medication changes
If has respiratory diagnosis O2
sat level
Non-medication intervention
resident response
Medication intervention if
needed document response
Medication changes if applicable
and result of change

Dialysis Assess/Documentation
Prior to Leaving
Date/Time
Observation of shunt
Assessment of skin
Meal consumption: Indicate if
food sent with resident.
Fluid consumption
If edema noted, how much?
(Write note for Dialysis team.)

Dialysis Assess/
Documentation on Return

Nutritional Status

Falls

Date/Time
Observation of Shunt
Skin Assessment
Edema
Ask about lunch consumption/
fluid intake
Review Dialysis notes:
Document weight, amt. fluid
pulled off, how resident tolerated
dialysis, any other pertinent
information from dialysis notes

Date/Time
Incident specifics (What is
observed.)
Vital signs (lying and standing B/P)
If diabetic, blood sugar
If respiratory diagnosis
O2 sat level
Injury?
What resident was trying to do
Interventions tried
Resident response to
interventions (Add intervention to
Care Plan if effective.)
MD and family notified?

Pain (Routine)
Assessment/Documentation

Pain (PRN)
Assessment/Documentation

Date/Time
Location of pain
Description of pain and score on
pain scale 0-10
If pain noted: On scale of 1-10,
what is residents goal for pain
relief?
Does pain limit ADL function
during day?
Does pain interfere with sleep?
Is residents pain goal met?
Was physician notified if Tx not
effective?

Date/Time
Location of pain
Description of Pain burning,
sharp, etc.
On scale of 0-10, how severe is
pain?
On scale of 0-10 what is residents
goal for pain relief?
Does pain limit ADL function during
day?
Does pain affect sleep?
Indicate PRN med given/document
on scale of 0-10 pain level 30 min.
to 1 hr post med
Did resident meet pain goal?

Swallowing disorders:
i.e. choking, holding food in
mouth, pain when swallowing
Oral and dental status
Complaints of poor appetite
% of p.o. intake
Amount of parenteral or tube
feeding
Weight loss
Interventions and response to
them
RD requested

Restorative Nursing Services

Chart reason for and effect of
service of the following:
Urinary and/or bowel toileting
program
Passive and/or active ROM
Splint or brace assistance
Bed mobility and/or walking
training
Transfer training
Dressing and/or grooming
training
Eating and/or swallowing
training
Amputation/prosthesis care
Communication training

Special Treatments,
Procedures and Programs
Chart date, time and effect if
receives any of the following:
Chemotherapy
Radiation
Oxygen therapy
Suctioning
Tracheostomy care
Ventilator or respirator
BIPAP/CPAP
IV medications
Transfusions
Dialysis
Hospice Care
Respite Care
Isolation
Vaccinations

Documentation is a matter of
good clinical practice and is an
expectation of trained and
licensed health care professionals.

This material was prepared by Alliant | GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily
reflect CMS policy. Acknowledgement: Patricia S. Harrison, B.S., R.N., C-RN LTC Consultant. Publication No. 10SOW-GA-IIPC-12-57