TABLE OF CONTENTS. Medicare Charting Guidelines... Section 3 Documentation Guideline Procedures...1 Medicare Documentation Guidelines...

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1 TABLE OF CONTENTS Medicare Skilled Nursing Training Handout...Section 1 Post Test...1 Training Content...3 Nursing Documentation Subjective/Objective Statements...22 Supportive Nursing Documentation...23 Medicare Skilled Coverage Checklist...26 Case Studies...36 Skilled Level of Care Criteria Management...Section 2 Medicare Coverage Chart...1 Continued Stay Requirements & Documentation...2 Stand Up Report...7 Weekly Meeting Tool...9 SNF Level of Care...13 Medicare Charting Guidelines... Section 3 Documentation Guideline Procedures...1 Medicare Documentation Guidelines...2 Manual includes: Manual CD - Includes forms and charting guidelines in Word Audio CD - Training audio CD, listen to audio CD while reviewing the manual material. This audio CD walks you through the material to provide training to skilled level of care. It is strongly recommended that the audio training CD be used to compliment the training experience. It is suggested that staff development listen to CD prior to providing training for front-line staff. Another option is to play the CD for all front-line staff.

2 Medicare Skilled Nursing Documentation Eligibility Requirements Three (3) consecutive midnight stay as an inpatient in an acute care hospital Acute Psych Rehab Daily Skilled Service Provided by Licensed Personnel As a Practical Matter must be provided in a SNF Developed by Polaris Group (800) Additional Requirements Skilled Services provided pursuant to a physician s order Physician Certification required at admission, on or before day 14, and every 30 days thereafter. The beneficiary must be admitted to the SNF for skilled care within 30 days of hospital discharge 30 day transfer rule. The exception to this is medical predictability. Developed by Polaris Group (800) Practical Matter Test Based on the individual s condition and the availability and feasibility of using more economical alternatives. As a practical matter skilled services can only be provided in a SNF if they are not available on an outpatient bases OR If transportation to the closest facility would be: An excessive physical hardship Less economical Less efficient or effective than an in-patient institutional setting Developed by Polaris Group (800) Polaris Group (800) Page 5 of 40

3 Nursing Documentation Subjective/Objective Statements # Subjective Statement Objective Statement 1. Cannot follow simple command of go into bathroom and brush your teeth. Requires direct supervision to walk into the bathroom and with toothbrush placed in hand, resident will brush teeth. When a single food item and one utensil are given to resident, he will eat independently. When the CNA hands the resident a sock and told to put it on his foot, the resident can do so. 2. Resident demanding today. On call bell 15 times in ½ hour. 3. Combative. Biting, scratching and kicking. Striking out at CNAs during a.m. care. Able to prepare injection site aseptically, independently but 4. Poor learner, slow learner. requires verbal cueing. Appears to understand. 5. Choking after every few bites of food. 6. Small amount of drainage on dressing. Able to return demonstration. Coughing and clearing throat after every two - three bites of food. Dime size (or measured amount) of green purulent drainage. 7. Antibiotic therapy continues. Lung sounds clear, no nausea or vomiting, no skin rash noted T P R 8. Wound healing well. Wound bed 5 cm in circumference and 1 cm in depth. Pink granulation tissue noted 2 cm around inside circumference. 1 cm open area noted in center of wound bed. Open area is red with no drainage or odor. Skin surrounding wound intact. Pain during treatment note at a pain scale of 5, Tylenol given prior to treatment. Developed by Polaris Group (813)

4 SUPPORTIVE NURSING DOCUMENTATION PHYSICAL THERAPY Overview: The following chart provides examples of how to document progress at least weekly in specific physical therapy situations. FUNCTIONAL SKILL Bed Mobility NURSING DOCUMENTATION EXAMPLE Resident holds onto side rails to pull self onto side. Two CNAs move resident up in bed with use of turning sheet and extensive assist. Supine to Sit --> Stand Transfers Ambulation Range of Motion Resident requires limited assist to sit up in bed and to swing legs over side ending in a sitting position. Resident can pull self to a sitting position with use of side rails. Can swing right leg to floor. CNA moves left leg to floor. Needs assist of 2 to lift resident from a sitting to standing position. Once standing can pivot to wheelchair and sit independently. Transfers from bed to wheelchair with limited assist and cueing of 1, to remind resident not to bear weight on left leg. Requires 2 to transfer, lifting resident from bed to chair. Need extensive assist of one and will pivot once lifted to a standing position. Resident can rise from chair with limited assist, but must be lowered into chair with weight bearing support. Ambulates 20 feet in hallway with 2 CNAs, limited assist is provided with one holding gait belt and one following behind with wheelchair. Resident ambulates bent at waist and will sit down without warning. Ambulates in room independently pushing wheelchair as support, requires one limited assist to ambulate in hall to dining room. Passive ROM provided by CNA during PM care to both upper extremities. Splint applied and therapeutic positioning provided to upper extremities as directed by therapy. Tolerated well. Developed by Polaris Group (813)

5 MEDICARE DOCUMENTATION GUIDELINES NAME: ADMISSION DATE TO CERTIFIED SECTION: RESIDENT/BENEFICIARY IS COVERED BY MEDICARE FOR: THE HIGHLIGHTED AND/OR HANDWRITTEN AREAS HAVE BEEN IDENTIFIED AS THE BASIS FOR MEDICARE COVERAGE. PLEASE ADDRESS THESE AREAS IN THE DAILY NURSING, AS WELL AS OTHER PROBLEMS OR CONCERNS REGARDING THE RESIDENT/BENEFICIARY S CARE OR CONDITION. CANCER 1. Vital signs Q 2. BP & Pulse Q shift 3. Anorexia 4. I & O, note fluid retention 5. Weight 6. Apprehension 7. Skin; odor from affected tissue (Wound Care) 8. Attitude; fatigue 9. Pain; location, type, duration, time it occurred, how treated results of treatment (medication, comfort, measures, etc.) 10. Activity, mobility 11. Sensitivity to chilling 12. If on Chemo/Radiation; report nausea, vomiting 13. Positioning techniques

6 MEDICARE DOCUMENTATION GUIDELINES NAME:_ ADMISSION DATE TO CERTIFIED SECTION: RESIDENT/BENEFICIARY IS COVERED BY MEDICARE FOR: THE HIGHLIGHTED AND/OR HANDWRITTEN AREAS HAVE BEEN IDENTIFIED AS THE BASIS FOR MEDICARE COVERAGE. PLEASE ADDRESS THESE AREAS IN THE DAILY NURSING, AS WELL AS OTHER PROBLEMS OR CONCERNS REGARDING THE RESIDENT/BENEFICIARY S CARE OR CONDITION. OBSERVATION & ASSESSMENT OF CHANGING CONDITION 1. SKIN CONDITION A. Integrity B. Measure and describe open areas or potential problems 2. PHYSICAL AND FUNCTIONAL STATUS A. Documentation assistance required for bed mobility, positioning, transfers, ambulation, endurance level with activity, ADLs B. Rehab evaluation (s) as appropriate: 1. PT 2. OT 3. ST 3. NUTRITION/HYDRATION STATUS A. Eating/swallowing impairment B. Skin turgor C. Special dietary needs D. Percent meals eaten/day 4. SYSTEM ASSESSMENT A. Mentation 1. Oriented times 2. Ability to follow instructions B. Cardiac and Respiratory 1. Body edema 2. Irregularities of pulse/apical/radial 3. Presence of wheezing, rhonchi by auscultation 4. SOB, cough, sputum C. Gastro Intestinal 1. Bowel sounds present 2. Gas, constipation, loose stools 3. Nausea 4. Hiatus, belching 5. Feeding tube-why? D. Genitourinary 1. Continent/incontinent 2. Candidate for bladder training 3. Foley catheter? Why? 4. Color, odor, sediment 5. RESPONSE TO TREATMENT A. Document response to any change in medication, e.g., cardiac, psychotropic, pain B. Response/progress regarding treatments 6. GENERAL NURSING OBSERVATION A. Note all observation that evaluate and identify needed changes or modifications in beneficiary care plan B. Document contact with the attending physician and any resulting action

7 Checklist for Assisting with Determination of Medicare Skilled Coverage Beneficiary Name: Medicare Condition/Diagnosis IN ORDER TO DETERMINE IF THE PATIENT MEETS THE CRITERIA FOR MEDICARE COVERAGE, PLEASE COMPLETE THE FOLLOWING QUESTIONNAIRE BY ANSWERING YES OR NO: 1) Three (3) midnights in-patient qualifying hospital stay or prior SNF stay? If YES, give dates of service for all prior stays and verify # of SNF days used. NOTE: After 100 days of SNF coverage, benefits are exhausted. If NO, STOP, resident is NOT Medicare qualified. 2) IS QUALIFYING HOSPITAL STAY OR PRIOR SNF STAY WITHIN 30 DAYS OF THIS ADMISSION DATE? If YES, continue to #3, if NO, STOP, patient is NOT Medicare qualified. NOTE: ONE EXCEPTION TO THE 30 DAY RULE-MEDICAL APPROPRIATENESS EXCEPTION - AN ELAPSED PERIOD OF MORE THAN 30 DAYS IS PERMITTED FOR SNF ADMISSIONS WHERE THE RESIDENT S CONDITION MAKES IT MEDICALLY INAPPROPRIATE TO BEGIN AN ACTIVE COURSE OF TREATMENT IN AN SNF WITHIN 30 DAYS AFTER HOSPITAL DISCHARGE, AND THIS IS ORDERED AT TIME OF DISCHARGE FROM HOSPITAL. 3) DOES THE RESIDENT REQUIRE 7 DAYS OF SKILLED NURSING OR 5 DAYS OF THERAPY (CAN BE A COMBINATION OF PT, OT, and ST)? If YES, continue to #4, if NO, STOP, patient is NOT Medicare qualified. 4) IS THERE A PHYSICIAN ORDER FOR THE SNF ADMISSION? If YES, continue to #5, if NO, contact physician regarding patient s eligibility status. 5) AS A PRACTICAL MATTER, IS A SKILLED NURSING FACILITY THE MOST APPROPRIATE PLACE FOR RENDERING CARE? Answer must be YES, continue to #6. 6) IS RESIDENT IN A MEDICARE CERTIFIED BED? If YES, continue to next section, if NO, NOTE: Medicare patients must be placed in a Medicare certified bed in order to be covered. Page 1 of 4

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