SNF therapy documentation

Skilled Nursing Facility: Importance of Different Types of Notes and Admission Assessment

What are some of the types of notes and what are advantageous to having those types of notes. Your admission note is critical from a nursing perspective because it sets the tone for what you're skilling the patient for.

So upon admission, you should have a very skilled person writing your note that talks about the person came in, what was the time and date? What was the mode of transportation because you want to support any ADL care that's being provided to assist extensive assist?

You want to talk about the diagnosis of the patient. If you have the information on that prior level of function but also what is the patient going to be skilled for upon admission. Because what happens is that note then could become a note that other people were referred to.

The next shift can look at that note, “Oh, okay. And they know what to document on for (eschewing) purposes.” You then should have skilled daily notes from a nursing perspective that clearly outlined daily skilled nursing services for.

Long Term Care Training Tip: Those notes can be summarized on a weekly basis and updated because patients will change. And their skilled needs will change. So you have a daily note and you're going along, you're writing your daily note and Medicare meeting comes along, your weekly Medicare meeting which every skilled nursing facility should have. And if you need details about Medicare meeting, that's another whole discussion.

But you need to find out a beneficiary review meeting. Sometimes it can be referred to but at that weekly meeting, you discuss what other skilled areas for the patient. And that's when a weekly note should be written updating the skilled nurse daily, nursing skilled areas for that patient so that each shift can see a note or at least each day can see a note so that the next person writing a note everyday should have listed out the skilled areas.

And if a staff member is not sure of a skilled area, encourage them to ask. What are (we going to station) for? I'm not sure. And it's not always obvious. So it's not a silly or a stupid question.

Long Term Care Training Information: So admission notes, there's some detailed explanation, there's some samples here, a daily note as well. There's some sample things in terms of a pulmonary assessment. Also descriptions for wounds and people will say to me, “Oh, well we have that because we have a treatment record.” But there should be acknowledgement by somebody on the floor in your daily nurse’s note but there is a wound that is being attended to and maybe refer the reader to the treatment record or your TAR.

For more information, visit our long term care training page

And then, so there are some samples of that on the slides. And we talked about beneficiary review meeting. Now the last several slides I really like where they talk about daily observation and assessment of the resident’s condition. And it's actually slide 81.

It begins and it goes through all of these different areas that could skill a patient and what you might document on. So, neurological, there was the slide. And these slides can be very useful for people if you had an area where people could sort of gauge up and view.

Maybe you make them into small cards that are laminated for a reference for people. So you would look at level of consciousness, people’s sides, reaction. If it's a respiratory patient, then you're looking at obviously if they have shortness of breath. But what are their lung-sound sound like? What's their respiration? What are their blood gases?

So writing a daily skilled note becomes a little bit easier when you have these chee chees or when you have something as a reference because at the end of a shift when you're documenting you're in out loud area where there's lots of patient, there's people approaching you, you're trying to remember what was the services that were provided for maybe, I don’t know, five patients, maybe eight patients. Who knows how many patients you have to document on?

So anytime you can have a visual reference for somebody, it takes some of that brain power out and your notes will be much more clearly written. So the slides go through, you know many different areas and give suggestions.

You know, urinary tract infection, you want to describe what's happening with the patient versus just no signs and symptoms. But give some descriptions of what is happening or talk about, you know, the fluids that the patient is taking and how often they did have to go to the bathroom.

And the nurse might not always have that information but that's why it's important to communicate with other members of the team, talk to the nursing assistants, set a time up during the day where they can communicate because nursing assistants has ample, ample information about these patients.

And oftentimes, quite frankly, nurses do get overwhelmed and they do have a significant amount going on. And so they might need a few pieces of information from the nursing assistant.

For more coding, billing and healthcare compliance information, visit our Health system conference page.