If anyone has written a book about LTC documentation, I sure would like to buy it! Guidelines, phrases, outlines would also suffice.
Late entry guidelines
Thanks in advance!!
The guidelines for documentation in LTC are the same as in the hospital. If you didn't document it, it didn't happen. Late entries: put the date it is, then "late entry for 1/24/08 for example and then write your note. When charting on Medicare or Managed care patients, make sure your note includes specifics about the patient's diagnosis. If they were admitted status post hip fracture, for example, your note should include level of pain, anticoagulants, assessment of the incision site, how they are doing with therapy. In other words, document on the reason Medicare is paying for them to be there. "Pleasant, ate well, bowel sounds in all 4 quads"...I see that note more often than not. Medicare doesn't give a care if they are pleasant.
Last edit by sirI on Jan 28, '08