Introduction
Long term care nursing documentation can be very time consuming. Having the right form for the job at hand makes the task easier and quicker. The right form will have all of the essential information, but no more, and be organized logically for the task.
The form templates in this manual cover all the basic needs of data collection, assessment, monitoring, and tracking. All the forms in the book are included on the CD-ROM, and can easily be made facility and resident specific with a word processor. Having the master forms on CD enables the user to change them as the facility policies evolve. It also assures clean copy.
For the 2009 Second Edition, forms have been updated to ensure compliance with the change to MDS version 3.0 and with all of the federal regulations and guidelines updated during the past year
The 20 CAT Modules in this book are easy-to-use checklists of triggers, and include many other very pertinent MDS items to help make the care-planning decision clearer.
The applicable MDS sections are listed on the left side of the form, and flow alphabetically in MDS order for fast reference. Ample space is at the bottom of the form for CAT Summary documentation notes.
The Skilled Charting Guidelines provide clear instructions for the supporting documentation required for Medicare reimbursement, and can also assist in determining what conditions may be considered skilled care. They are often placed in front of the nurses’ notes in the resident’s chart to clarify what must be charted on the Medicare resident.
Forms for Long Term Care will benefit:
Charge Nurses
MDS Coordinators
Directors of Nursing
Restorative Nurses
Quality Assurance departments
Social Services departments