documentation
Nursing Documentation
Guideline: In ICFs/MR, information reflecting the nursing plan of care as well as other pertinent information should be documented in the individual’s record in an accurate, timely, and legible manner.
DEFINITIONS:
Individual’s record: A permanent legal document that provides a comprehensive account of information about the individual’s health care status.
Primary care prescribers: Physicians, nurse practitioners, and physician’s assistants who provide primary care services and are authorized to prescribe medications and treatments for people on their assigned caseloads.
RATIONALE:1
1.
Documentation in the individual's record facilitates communication among professionals from different disciplines and on different shifts. It provides information so that health care providers can deliver care in a coordinated manner.
2.
Information in the individual’s record is a source of data for quality assurance and peer review programs.
3.
Reimbursement from third-party payers (i.e., Medicaid, Medicare) is based in part on the quality and timeliness of nursing care reflected in the individual’s record.
4.
The individual’s record serves as a legal document that may be entered into courtroom proceedings as a record of care the person received.
EXPECTED OUTCOMES:
Nursing Assessment
Documentation should reflect that nursing assessment occurs on a timely and regular basis.
1.
The admission assessment should be completed on the day of admission. Pertinent results of the assessment should be communicated to the primary care prescriber as warranted. 2.
All aspects of the Physical Health section of the Single Plan should be completed prior to the annual team meeting.
3.
A physical nursing assessment should be completed quarterly for those individuals who do not require a medical plan of care. A primary care prescriber’s examination may be used as a quarterly assessment required for those individuals for which 24 hour nursing
Guideline: In ICFs/MR, information reflecting the nursing plan of care as well as other pertinent information should be documented in the individual’s record in an accurate, timely, and legible manner.
DEFINITIONS:
Individual’s record: A permanent legal document that provides a comprehensive account of information about the individual’s health care status.
Primary care prescribers: Physicians, nurse practitioners, and physician’s assistants who provide primary care services and are authorized to prescribe medications and treatments for people on their assigned caseloads.
RATIONALE:1
1.
Documentation in the individual's record facilitates communication among professionals from different disciplines and on different shifts. It provides information so that health care providers can deliver care in a coordinated manner.
2.
Information in the individual’s record is a source of data for quality assurance and peer review programs.
3.
Reimbursement from third-party payers (i.e., Medicaid, Medicare) is based in part on the quality and timeliness of nursing care reflected in the individual’s record.
4.
The individual’s record serves as a legal document that may be entered into courtroom proceedings as a record of care the person received.
EXPECTED OUTCOMES:
Nursing Assessment
Documentation should reflect that nursing assessment occurs on a timely and regular basis.
1.
The admission assessment should be completed on the day of admission. Pertinent results of the assessment should be communicated to the primary care prescriber as warranted. 2.
All aspects of the Physical Health section of the Single Plan should be completed prior to the annual team meeting.
3.
A physical nursing assessment should be completed quarterly for those individuals who do not require a medical plan of care. A primary care prescriber’s examination may be used as a quarterly assessment required for those individuals for which 24 hour nursing