LTC Health Information Practice & Documentation Guidelines
Table of Contents
6.0 DOCUMENTATION IN THE LONG
TERM CARE RECORD
Documentation in long term care
has become increasingly complex as the residentís clinical needs have become
more complex, regulations and surveys more stringent, documentation Ėbased
payment systems implemented, and litigation/legal challenges have increased.
This section creates a foundation
for documentation by addressing the minimum content as required by federal
regulation for long term care facilities and fundamental practice standards,
but generally does not outline specific content. The tag number for the Federal
Condition of Participation is referenced where applicable. This section also
addresses common documentation issues and concerns and establishes guidelines
or provides recommendations on how to handle common problem areas.
As long term care facilities establish
or review their documentation system, the practice guidelines and federal
regulations identified below must be taken into consideration. In addition
to the federal regulations and professional practice standards, it is imperative
to review and incorporate state regulations, accreditation requirements (i.e.JCAHO),
and payer requirements into the documentation systems established.
Because documentation systems
should be created to meet the needs and unique practices of a long term care
facility or organization, this section does not recommend a specific system.
Instead, minimum requirements are established, issues to consider are discussed,
and guidelines are provided to assist facilities with implementing or evaluating
a documentation system while retaining flexibility in how it can be created.
6.0.1 Federal Regulations Pertaining
to Clinical Records:
Federal regulation (F514)
requires that a the facility "must maintain clinical records on each
resident in accordance with accepted professional standards and practices
that are complete, accurately documented, readily accessible and systematically
The guidelines in this document
provides the foundation for "professional standards and practices"
as established by AHIMA for clinical records/health information systems.
Other professional organizations may have additional standards in dealing
with documentation unique to a specific discipline.
6.0.2 Purpose of the Documentation
On a fundamental level, a
complete record contains an accurate and functional representation of
the actual experience of the individual in the facility. It must contain
enough information to show that the facility knows the status of the individual,
has adequate plans of care and provides sufficient documentation of the
effects of the care provided. Documentation should provide a picture of
the resident and their response to treatment, changes in condition and
changes in treatment.
6.0.3 Elimination of Duplication/Redundant
Information when Evaluating/Implementing a Documentation System:
One of the most significant
problems found in many documentation systems is the duplication or redundant
information that is collected in the medical record. Not only is this
inefficient, but it creates conflicts and contradiction in the documentation
that leads to confusion and diminishes the credibility of the record.
A common problem found in long term care records is the duplication of
information that is collected on different assessments and between the
disciplines. To address this issue, long term care facilities should evaluate
their entire documentation system looking at the data elements collected
by all disciplines and eliminating areas of duplication.
One method to use in evaluating
duplication is to create a data dictionary or a list of documentation
elements collected in the entire documentation system, identify where
it is collected (i.e. what form), how often, and by whom. Once it is known
where information is collected and areas of overlap are identified, decisions
can be made on elimination of duplicative information. When working with
different disciplines, the goal should be creating a system that works
together as an interdisciplinary team rather than segregating assessments
and documentation into department-specific documents that donít work together
but increase the likelihood of contradictions.
6.1 DOCUMENTATION CONTENT
IN A LONG TERM CARE RECORD:
6.1.1 Admission Record:
Every clinical record should
have a face sheet or admission record that provides demographic information,
responsible party and contacts (F157), financial and insurance information,
and contact information for outside professionals involved in the residentís
care (i.e. attending physician, alternate physician, etc.). The face
sheet should be kept up to date as changes occur.
Assessments are critical to
the documentation system in a long term care record. It is important to
recognize that assessments can be documented in a variety of ways but typically
fall into two groups Ė completion of an assessment form or documenting an
assessment narratively. Many "assessments" collect information
or identify a condition. To be complete, they should also include conclusions,
recommendations and interventions. To be an assessment rather than just
a data collection tool, the following elements should be in place:
- Evaluation -- data is collected
relevant to the issue being assessed.
- Conclusion -- the assessor
interprets and documents their conclusions based on the data collected
- Plan -- based on the type
of assessment, there should be a plan with recommendations and follow-up.
6.2.1 Integrating Assessments
with RAI Process:
As LTC facilities evaluate
their documentation system, the goal should be to create an interdisciplinary
assessment process that uses the RAI as the foundation rather than a
supplement. With the MDS and RAPS as the main assessment tools, other
assessments would collect information that supplements the comprehensive
assessment rather than readdress it.
6.2.2 Types of Assessments
The following assessments
represent those required by federal regulation or those that have become
a standard of practice in the industry. Although many of the assessments
are completed on a separate form, the format may vary or the assessment
may be documented in narrative notes.
126.96.36.199 Preadmission Assessment:
Completion of a preadmission
assessment is not required by federal regulation, but is commonly
completed to determine the needs of the resident and assure that
the facility has adequate resources and expertise to provide care.
As Medicare reimbursement moved to a prospective payment system
partially based on services delivered prior to admission, the preadmission
assessment has taken on a new purpose in providing supporting documentation
for the MDS. If the information from the preadmission assessment
is used to support other documents in the record including the MDS,
it should be incorporated into the legal medical record and meet
legal documentation requirements (completed in ink, authenticated,
188.8.131.52 Admission Assessment:
An admission or readmission
assessment typically incorporates items that would be considered
a nursing assessment or physical examination. Although there is
not a federal regulation to perform an admission assessment, professional
practice standards for the industry indicate that an admission assessment
should be completed. State regulations may provide specific detail
on information to collect such as vital signs, a review of systems,
pain, etc. The purpose of the admission assessment is to collect
baseline information on the resident and assist with initiating
an initial admission care plan until the MDS, RAPS and care plan
process is completed.
184.108.40.206 Fall Assessment:
(F324) Based on the
comprehensive assessment, the RAI incorporates a fall risk assessment
into the MDS and RAPS. The facility must identify each resident
at risk for accidents and/or falls and adequately care plan and
implement procedures to prevent accidents. On admission, due to
the time delay in completing the RAI, it is recommended that the
risk for falls be assessed on admission/readmission (i.e. could
be incorporated into admission assessment) and appropriate action
taken. The RAI can be used to assess fall risk at times thereafter
(quarterly, annually, and significant change in condition). Another
type of assessment should be completed after a fall. A post-fall
assessment should assess the circumstances of a fall, draw conclusions
about the cause of a fall, and implement a plan if appropriate.
This type of assessment may be completed in the narrative notes
or on a separate form.
220.127.116.11 Skin Assessment:
(F314) Based on the
comprehensive assessment the facility must ensure that a resident
who enters the facility without a pressure sore does not develop
pressure sores unless the individualís clinical condition demonstrates
they are unavoidable. An assessment of current skin status upon
admission/readmission is recommended to serve as a baseline. A resident
having pressure sores must receive the necessary treatment and services
to promote healing, prevent infection and prevent new sores from
18.104.22.168 Bowel and Bladder
(F316) Based on the
comprehensive assessment the facility must ensure that a resident
who enters without a catheter is not catheterized without medical
justification, a resident who is incontinent of bladder receives
appropriate treatment and services to prevent urinary tract infections
and to restore as much normal bladder function as possible.
22.214.171.124 Physical Restraint
(F221) Prior to a physical
restraint being used an assessment must be completed to determine
whether a restraint is necessary and if so, the least restrictive
device to treat the residentís medical symptom(s). Prior to a restraint
being applied, the facility must assess the resident's bed mobility,
ability to transfer between positions, ability to transfer to and
from bed or chair, and ability to stand and transfer to the toilet
and so forth. Once a restraint is applied, the facility must reassess
its use on a periodic basis. The facility should use the Physical
Restraint RAP to evaluate the appropriateness of restraint use.
(Transmittal 20 - revisions to Appendix PP of the State Operation
Manual effective 9/2000)
(F176) The interdisciplinary
team must determine that it is safe for the resident to self administer
drugs before the resident may exercise that right. Appropriate notation
of these determinations should be placed in the residentís care
plan. If the resident chooses to self-administer drugs this decision
should be made by the time the care plan is completed within seven
days of the completion of the comprehensive assessment and then
on an on-going basis.
126.96.36.199 Nutrition Assessment:
(F325) The resident
must maintain acceptable parameters of nutritional status taking
into account the residents clinical condition or other appropriate
intervention when there is a nutritional problem. The nutrition
assessment should address these issues and include identification
of the factors that put the resident at risk for malnutrition. Evidence
of review of the RAP for Nutritional status should be present to
assess the causal factors for decline, potential for decline or
lack of improvement for residents at risk. The individual goals
of the plan of care must be periodically evaluated and if not met
alternative approaches should be considered or attempted.
(F248) The resident's
activity program should occur within the context of each residentís
comprehensive assessment and care plan. Clinical records and activity
attendance records should reflect individual resident history, interests
and preferences indicated by the comprehensive assessment and consistent
with the intent of the RAI/care plan process. Outcomes/responses
to activities interventions are identified in the reassessment of
188.8.131.52 Social Service:
(F250) It is the responsibility
of the facility to identify the medically related social service
needs of the resident and assure that the needs are met by the appropriate
discipline. Clinical records should reflect how facility staff implement
social service interventions; evidence of monitoring the residentís
progress in improving physical, mental and psychosocial functioning;
goal attainment been evaluated and the care plan changed accordingly.
Evidence should support that social services interventions successfully
address residentsí needs and link social supports, physical care
and physical environment with residentsí needs and individuality.
184.108.40.206 Mental and Psychosocial
(F319) Based on the comprehensive
assessment the facility must ensure that a resident who displays mental
or psychosocial adjustment difficulty, receives appropriate treatment
and services to correct the assessed problem. (F320) For a resident
whose assessment does not reveal a mental or psychosocial adjustment
difficulty, there is not a pattern of decreased social interaction
and/or increased withdrawn, angry or depressive behaviors, unless
the residentís clinical condition demonstrates that such a pattern
220.127.116.11 Restorative/Rehab Nursing
(F317) Based on the comprehensive
assessment the facility ensures that a resident who enters without
limited range of motion does not experience a reduction in range of
motion unless the residents clinical condition indicates that it is
unavoidable. (F318) A resident with limited range of motion, receives
appropriate treatment and services to increase range of motion and/or
to prevent further decline.
6.3 Resident Assessment Instrument
(RAI) - MDS and RAPS
(F274) Each facility must complete
a comprehensive assessment which is based on a uniform data set. Facilities
must use their State specified RAI (which includes both the MDS, utilization
guidelines and the RAPS) to assess newly admitted residents within 14 days,
conduct annual reassessment, and assess those residents who experience a
significant change in status or when completing a significant correction
of a prior full assessment. . No less than once every quarter (92 days),
facilities must review the comprehensive assessment to assure that the residentís
assessment is accurate and reflects the residentís current status.
A comprehensive assessment must
be completed within 14 days after the facility has determined that there
has been a significant change in the residentís physical or mental condition
(F274). A significant change is defined as a major decline or improvement
in the residents status that will not normally resolve itself without further
intervention by staff or by implementing standard disease related clinical
interventions, that has an impact on more than one area of the residentís
health status and requires interdisciplinary review of the plan of care
The facility is responsible
for addressing all needs and strengths of residents regardless of whether
the issue is included in the MDS or RAPS. The facility is also responsible
for addressing the residentís needs from the moment of admission.
The MDS is also used to determine the reimbursement level under the prospective
payment system for Medicare Part A residents in a SNF. Based on the MDS
scoring, a Resource Utilization Group (RUG) is assigned which determines
the per diem payment. While on Medicare Part A, the PPS MDS schedule includes
a 5, 14, 30, 60, and 90 day assessment. An OMRA (Other Medicare Required
Assessment) may also be completed in specific situations. In addition to
Medicare, some states may also use the MDS to determine the payment level
for medical assistance.
6.4 Care Plan:
The care plan is the foundation
that provides direction to the interdisciplinary team and staff on providing
care and treatment to the resident. The care plan should be the central
focus for on-going documentation of the residents care, condition, and needs.
(F279) The facility must develop
a comprehensive care plan for each resident that includes measurable objectives
and timetables to meet a residentís medical, nursing, and mental and psychosocial
needs that are identified in the comprehensive assessment. The care plan
must describe the services that are to be provided to attain or maintain
the residentís highest practicable physical, mental and psychosocial well-being;
any services that would otherwise be required but are not provided due to
the residentís exercise of rights including the right to refuse
treatment. The care plan must reflect intermediate steps for each outcome
objectives if identification of those steps will enhance the residentís
ability to meet his/her objectives. Facility
staff will use these objectives to monitor resident progress. Facilities
may need to prioritize their care plan interventions. This should be noted
in the clinical record or on the plan of care.
The care plan must be prepared
by an interdisciplinary team that includes the attending physician, a registered
nurse with the responsibility for the resident and other appropriate staff
and disciplines as determined by the residentís needs and to the extent
practicable the participation of the resident, the residents family or the
residentís legal representative. There should be evidence that the care
plan is periodically reviewed by a team of qualified persons after each
assessment and as the residentís status changes.
(F280) A comprehensive
care plan must be completed within 7 days of completion of the comprehensive
assessment. Completion or updating of the care plan should follow
the comprehensive assessment since the assessment provides the foundation
or analysis of a problem resulting in the goals and interventions
on the care plan. The care plan is reviewed and updated after each
scheduled comprehensive assessment Ė admission, quarterly reviews,
annually, and with a significant change in condition.
6.4.2 Care Conference:
(F280) In completion of
the care plan, the professional disciplines must work together to provide
the greatest benefit to the resident. The mechanics of how the interdisciplinary
team meets its responsibilities in developing an interdisciplinary care
plan (e.g. a face-to Ėface meeting, teleconference, written communication)
is at the discretion of the facility. The facility should encourage
residents, surrogates, and representatives to participate in care planning
including encouraging attendance at care planning conferences.
6.4.3 Admission/Interim Care Plan:
Upon admission, a brief
initial care plan should be developed to carry through until the residentís
comprehensive assessment and care plan have been developed. The care
plan should address the primary reason for admission and treatment and
the residentís most immediate care needs. Usually the plan includes
clinical and/or rehab needs and nutritional needs.
6.4.4 Integrating Acute
Problems into the Care Plan:
When temporary or acute
problems arise, the facility documents an assessment of the problem
and implements a plan. It is at the facilities discretion on how the
acute problem is incorporated into the care plan. The acute problem
can be incorporated into the comprehensive care plan or could be documented
on a separate acute or temporary care plan form. If an acute care plan
is used, there must be documentation of the problem, interventions and
6.4.5 Timeliness of Completion
of Care Plan:
The comprehensive care
plan should be in the medical record within 7 days after completion
of the comprehensive assessment. For example, if the care conference
is held 7 days after the completion of the comprehensive assessment,
the updated care plan would be on the record or available for staff
to use on that day.
6.4.6 Authenticating Changes
to Care Plan:
Since the care plan is a
key document that should be kept up to date at all times, changes are
frequently made. Each time there is a change made on the care plan,
staff making the change must follow proper legal documentation guidelines
and authenticate and date the entry. This includes making a new entry,
changing, or discontinuing an entry.
6.5 Narrative Charting and Summaries:
It is a standard of practice
to write a note at the time of admission that documents the date and
time of admission, how transported, the reason for admission, and the
residentís condition. State regulations may have specific requirements
for admission documentation and the time frame for completion.
6.5.2 Content of Narrative
A complete record contains
an accurate and functional representation of the actual experience of
the individual in the facility. It must contain enough information to
show that the facility knows the status of the individual, has adequate
plans of care and provides sufficient documentation of the effects of
the care provided. Documentation should provide a picture of the residentís,
including response to treatment, change in condition and changes in
treatment. Good practice indicates that for functional and behavioral
objectives the clinical record should document change toward achieving
care plan goals.
6.5.3 Monthly Summary Charting:
Federal regulations do not
require the completion of a summary note, however, some states may require
a summary per licensure or reimbursement regulations. Typically summary
documentation provides a mechanism to provide an update of the residentís
The summary note should be based on the care plan. If there are changes
in the residentís status from the previous summary or not reflected
in the care plan, the summary should describe the residentís status,
the reason for the change, and the updates made to the care plan.
If flowsheets or checklists are used, they should contain an area for
narrative documentation to supplement the check boxes, all fields should
be completed, if a section does not apply the writer should indicate
that is not applicable. When using a flowsheet or checklist, the care
plan should still be the basis for the documentation. If there is a
change from the previous summary or a change not reflected in the care
plan, a note should be written explaining the reason for the change
and the updates made to the care plan.
The use of a monthly summary
note or flowsheet should not preclude staff from maintaining documentation
throughout the month that reflects any changes in condition or status.
6.5.4 Integrated vs. Disciplinary
or disciplinary progress notes may be used at the facility discretion.
There are advantages and disadvantages to each type of progress note.
With integrated progress notes, all disciplines document on one progress
note form found in one section of the medical record. Disciplinary progress
notes separate narrative notes on different forms based on department
6.6 Medicare Documentation:
Medicare documentation must
provide an accurate, timely and complete picture of the skilled nursing
or therapy needs of the resident. Documentation must justify the clinical
reasons and medical necessity for Medicare part A coverage, the skilled
services being delivered, and the on-going need for coverage. Documentation
along with data gathered from observation and interviews should support
the MDS used to determine the Resource Utilization Group (RUG payment level)
for the Medicare recipient. The medical record must also support the ancillary
services provided to the resident and billed to Medicare by documenting
that the services were both delivered and medically necessary.
Note: Some Fiscal Intermediaries
(FI) and other payers may have specific local policies pertaining to MDS
and other supporting documentation, content and format. When developing
documentation systems for Medicare, check with your FI to determine any
6.6.1 Skilled Nursing/Therapy
The medical record must
prove that the resident needed and received skilled services on a daily
basis (either nursing or therapy). Medicare charting may be more frequent
if necessitated by the residentís condition. The content of the documentation
is specific to the clinical reasons for coverage and services delivered
and should be objective and measurable. Medicare worksheets can
be helpful in focusing charting to the specific service delivered, related
clinical issues, and the residentís response to care. When therapy services
are justifying Medicare coverage, nursing documentation should be consistent
with therapy documentation addressing how skills learned in therapy
are applied on the nursing unit.
The methods for charting
can vary based on the reason for Medicare coverage and the services
delivered Ė documentation can be written narratively, captured on flow
records or graphics, charting by exception, through structured notes
like SOAP, etc.
In addition to documenting
daily skilled services, the medical record should also contain documentation
supporting the reason for coverage/non-coverage.
6.6.2 Supporting Documentation
for the MDS:
Since the MDS is the basis
for determining the payment/RUG class, the medical record documentation
should support the answers on the MDS within the time frame established
by the assessment reference date.
Note: Some case-mix states will stipulate the specific source document
that is allowable in supporting the MDS data and/or additional State
specific documentation requirements.The
following are types of supporting documentation for the MDS
The following are examples of types of supporting documentation for
6.6.3 Therapy Treatment Time:
The individual and group
therapy treatment minutes for each resident must be documented in the
medical record for all dates in which services were delivered. The treatment
minute documentation is then used to complete and support the MDS and
RUG level. In addition to treatment time, the RAI manual requires that
the physician order must include a statement of the frequency, duration,
and scope of treatment.
The ADL section of the MDS
has an impact on all RUG payment categories for Medicare. The documentation
in the medical record should provide support for the scoring on the
MDS along with observation and interviews.. A facility may utilize ADL
charting tocollect information from all three shifts during the 7 day
observation period. If the staff member assessing the ADL status and
completing the MDS disagrees with the supporting documentation, a clarification
note can be written documenting the rationale for the ADL scoring on
and Behavior Documentation:
Mood and possibly behavior
scoring on the MDS can impact the Medicare RUG payment category. Because
these sections on the MDS requires the reporting of the frequency of
the mood or behavior problem, the medical record should provide supporting
documentation which quantifies the frequency reported.
Certain services provided
in the hospital are documented on the MDS and will impact the RUG class/payment
category. It is important to obtain supporting documentation from the
hospital to justify the MDS. A preadmission assessment that captures
hospital services and dates of delivery could also be used to support
the MDS. When used in this manner, the preadmission assessment should
be considered part of the residentís permanent record and meet the legal
6.6.7 Medicare Certification/Recertification:
Each resident on Medicare
must have a Medicare part A certification/recertification completed
and signed by a physician knowledgeable of the residents care and treatment.
The certification/recertification should include the reason for Medicare
coverage and skilled services delivered. Certifications are required
upon admission, on day 14, and then every 30 days thereafter while the
resident continues to be Medicare part A
Therapy Documentation Ė (On Hold)
6.8 Physician Documentation:
6.8.1 Physician Progress Notes:
(F386) Progress notes must
be written, signed and dated with each visit (at least every 30 days
for the first 90 days after admission, and at least once every 60 days
thereafter). Progress notes should contain information pertaining to
the following issues:
- Each physician visit
should include an evaluation of the residentís condition, treatment
and a review of, and a decision about, the continued appropriateness
off the residentís condition and current medical regime.
- Progress notes should
reflect the continuity of care in maintaining or improving a residentís
mental and physical functioning status.
- Progress notes should
indicate the residentís progress or problems in maintaining or improving
their mental and physical functioning status.
- Progress notes identify
primary risk factors and causal factors contributing to clinical conditions,
functional decline, deterioration or potential for, and lack of improvement
and whether avoidable or unavoidable.
- Progress notes clinically
validate need for medical intervention or justification for decisions
- The physician should
review the residentís total program of care, including medications
and treatments at each visit.
If a physician dictates
a progress note, a brief note should be entered into the record at
the time of the visit stating that dictation will follow. If there
has been an acute change in the residentís condition, the physician
should write a note for the medical record in addition to the dictated
progress note. The dictated progress note should be received by the
facility and filed in the medical record within 7 days. The facility
should have a monitoring system to assure that dictated notes are
received within the appropriate time period.
6.8.3 NP/PA Documentation:
Federal regulations allow
a NP/PA working with a physician to make every other required physician
visit after the initial visit. The NP/PA must write a progress note
at the time of the visit and should follow the same guidelines for
content as defined above. The federal regulations do not require countersignature
by the attending physician, however, state law usually defines the
NP/PA authority and should be reviewed to determine if countersignatures
6.8.4 History and Physical:
Federal regulations do
not require the completion of a history and physical at the time of
admission or on a periodic basis thereafter. Facility policies requiring
a H&P should be developed based on state regulations and applicable
6.8.5 Other Professional
and Consultation Records/Notes:
If the resident requires
a consultation with a specialist, the medical record should contain
documentation of the visit, progress note, and recommendations. For
consultations that occur out of the facility, a separate referral/consultation
record can be sent to the physician to obtain documentation for the
residentís long term care record.
6.8.6 Documenting Resident
The medical record contain
a record of the residentís medical diagnoses. The diagnosis/problem
list should include the on-set date for the diagnosis if known (if
on-set date not known, use the date from physician supporting documentation),
a statement of the diagnosis/condition, the applicable ICD-9-CM
code, and resolve date.
18.104.22.168 Supporting Documentation
The diagnoses recorded
in the residentís medical record must be supported by physician
documentation. Supporting documentation includes written progress
notes, transfer forms, hospital documentation (i.e. H&P, discharge
summary), consultation reports, etc. that have been signed by the
physician. If a more specific diagnosis is needed, the physician
must be consulted and provide supporting documentation. Clinical
staff (i.e. nursing or therapy) can not diagnosis or determine a
more specific diagnosis without consulting with the physician and
obtaining supporting documentation.
22.214.171.124 Resolving Diagnoses:
On a regular basis (i.e.
quarterly with each care conference, at the time of physician visits,
etc.), the diagnosis/problem list should be reviewed and diagnoses
resolved that are no longer current. If a diagnosis has resolved
the physician must provide supporting documentation that the diagnosis
is no longer active unless the condition is self-limiting such as
a UTI or URI
6.9 Physician Orders:
(F271) At the time a resident
is admitted, the facility must have physician orders for the residentís
immediate care. The orders should include at a minimum dietary, drugs
(if necessary), and routine care to maintain or improve the residentís
functional abilities until staff can conduct a comprehensive assessment
and develop an interdisciplinary care plan.
6.9.2 Content of an Order:
A physician order should
include the drug or treatment and a correlating medical diagnosis
or reason. For a medication order, the route, dosage, frequency, strength,
and reason for administration should be documented in the text of
the order. For parenteral or enteral nutrition therapy include all
required components Ė fluid, amount, flow rate, pump/gravity/bolus
use, etc. For some orders such as antibiotics, a stop date is also
6.9.3 Physician Order Recaps/Renewals:
On a regular basis (often
30 days or as required by state law), the current set of physician orders
are compiled for the attending physician to review and renew. F386 requires
the physician to review the orders at the time of the physician visit.
The current orders should be recapped on a physician order record, signed
and dated by the physician or their designee. Physician order recap
or renewal should not be completed via a review of the medication and
treatment records with a blanket statement to renew all orders. After
the physician has reviewed and renewed the orders, a nurse should review
the orders for changes and note the signed orders.
6.9.4 Telephone Orders:
Orders received by telephone
should be countersigned by the physician within the required time frame
as defined by state law. In absence of a state law, facility policy
should define the time frame for countersignature (e.g. 14 days). Federal
regulations do not specify a timeframe for countersignature by the physician.
6.9.5 Fax Orders:
(F386) Orders received and
signed via fax may be accepted until the original is provided. At that
time, the fax copy may be destroyed. When fax is used as a means of
communication with the physician, both the physicianís office and the
facility should retain the fax documents as part of the residentís medical
record. The physician's office should be able to produce the order with
the original signature upon request. All faxed information must be clearly
identified with the residentís name and medical record number.
6.9.6 Standing Order Policies:
Standing order policies
should be used with discretion. Legend drugs should not be included
on standing orders nor should standing orders be used in place of notification
to the physician of a change in status.(Note: Some states do not
allow the use of standing orders.)
Orders must be countersigned
within the required period of time usually determined by state law or
facility policy. Federal regulations do not define a time period in
which telephone orders are to be authenticated. All orders must be signed
by the authorizing physician. No physician will authorize through their
signature an order that was given/written by another physician. Various
methods for authenticating orders is acceptable Ė see legal documentation
section for acceptable methods.
6.9.8 Transcription of Orders
and Noting Orders:
orders, such as telephone orders, is a responsibility of professional
nurses (RN, LPN/LVN per scope of practice defined by State law/practice
acts), but can be delegated to a trained individual if allowed by state
law or practice acts. If the transcription process is delegated, the
nurse still must sign off on the order and retain responsibility for
accurate transcription. When a telephone or fax order is transcribed
into the medical record, it should be transcribed verbatim as given
from the physician.
Physician orders (recaps/renewals, telephone/verbal, or fax orders,
etc.) are to be noted by a licensed nurse by writing "noted",
dating and signing with name and title.
6.9.9 Contacting the physician
to obtain an order:
Nurses, therapists or other
professionals designated to take orders must first contact the physician
to obtain the order. Each residentís medical care must be supervised
by a licensed physician (F385). Licensed nurses are not authorized to
independently write physician orders without the explicit direction
of or by the attending physician. It is not acceptable to write a telephone
order, implement the order and then send the order for signature without
contacting the physician. The exception would be for a nurse practitioner
or physician assistant who have the authority by law and scope of practice
to write orders on behalf of a physician.
6.9.10 Discontinuing an order
when a new order is obtained:
When a physician changes
a physician order that is currently in place, the original order must
be discontinued first and a new order written that reflects the change.
physician order recaps/renewals after they have been signed:
Once the physician has signed
the physician order recap/renewals changes or updates may not be made
to the signed document. For example, new orders should not be added
to the recap after the physician has signed the document.
6.9.12 Processing physician
orders after hospitalization Ė "resume previous orders":
Upon a return from a hospital
stay or readmission, when an order to "resume all previous orders"
is given, the attending physician should be contacted to review the
previous orders to assure that they are still appropriate and would
not conflict with any new orders. Some states may not allow the use
of "resume all previous order" statements.
6.9.13 Verification of hospital
orders with attending physician:
All hospital orders should
then be reviewed and authorized by the residentís attending physician
6.9.14 Accepting orders from
Orders should only be accepted
from a nurse practitioner or physician assistant if state law allows
the NP or PA to give orders or prescribe and the attending physician
has given authorization through a scope of care agreement. Both the
scope of care agreement with the attending physician and a copy of the
NP/PAís license should be kept on file by the facility.
6.9.15 Accepting orders from
Specialists or Consultants:
As a general rule orders
from a physician other than the attending (specialist, consulting physician,
etc.) should be reviewed with the attending physician prior to implementation
unless the attending physician has given previous written direction
to accept the specialist/consultant order(s).
6.10 Pharmacy Drug Review:
(F428) A review of the
residentís drug regimen is required to be completed on a monthly basis by
a licensed pharmacist. The pharmacist must report any irregularities to the
attending physician and the Director of Nursing. The reports made by the pharmacist
must be acted upon.
6.11 Antipsychotic Drug Therapy:
(F330) At a minimum, the medical
record should include documentation of the specific condition, as diagnosed
and documented in the clinical record, which necessitates the use of antipsychotic
drugs. When antipsychotic drugs are used, the clinical record should contain
documentation that the resident has specific conditions found under the
Guidance to Surveyors in the federal regulations.
6.11.1 Dose Reduction Schedules
(F331) For residents who receive
antipsychotic drugs, the record should contain documentation of efforts
to gradually reduce the dosage and behavioral interventions, unless clinically
contradicted, in an effort to discontinue these drugs. If clinically contraindicated,
documentation by the physician should provide justification as to why
the drug must continue to be used and also why the dose of the drug is
clinically appropriate. The justification should include a diagnosis (along
with description of symptoms), a discussion of the differential psychiatric
and medical diagnoses, a description of the justification for the choice
of a particular treatment or treatments, and a discussion of why the present
dosage is necessary to manage the symptoms of the resident. The information
does not have to be found in the physicianís progress notes, but must
be included as part of the residentís clinical record.
6.12 Medication and Treatment
Medication and treatment records
are derived from the physician orders and document the delivery of ordered
6.12.1 Starting new Medication/Treatment
Records Upon Readmission/Hospital Return:
To eliminate possible errors
in transcription or administration of medications and treatments, new
medication and treatment records should be initiated with a return from
the hospital rather than continuing on the previous record. The new medication
and treatment records would be based on the new orders received after
6.13 Flow Sheets/Flow Records:
Although flow sheets or records
are generally not recommended for completion of summary or narrative charting,
they are helpful tools in recording many clinical data or service delivery.
6.13.1 Service Delivery Records:
ADL Flowsheets and NAR
Flowsheets: There is not a federal requirement to maintain ADL flowsheets
or Nursing Assistant flowsheets to document delivery of resident care
services. Their use should be based on facility/company standards or
State requirements. If ADL/NAR flowsheets are used, it is best if they
are tailored to the residentís care plan.
ADL flowsheets can be either
documented by nursing after consultation with direct care staff or by
the nursing assistant providing care. If the nursing assistant completes
the flowsheet, there should be a system to monitor completion every
An acceptable alternative
to using ADL/NAR flowsheets in supporting delivery of resident care
is to implement a facility policy indicating that the residentís care
plan and the facility standard of care will be followed. Exceptions
to the standard or deviations must be documented in the medical record.
In this method NAR Flowsheets would not be necessary. ADL flowsheets
to record resident assistance levels may still be helpful in providing
supporting documentation for the MDS.
Scoring on the ADL flowsheets
should be consistent with the scoring on the MDS to increase consistency
in data collection and assessment.
6.13.2 Other Clinical Flow Records:
There are many different
clinical flow sheets used to assist in data collection and assessment.
Examples of clinical flowsheets include injection site rotation, intake
and output, pressure ulcer flowsheets, Medicare flowsheets etc. Facility
discretion rather than federal regulations usually dictate when clinical
flowsheets are used. Flow records can be for 7 day, 14 days or monthly
depending on facility policy.
6.14 Labs and Special Reports:
All laboratory, radiology, and diagnostic services must be ordered by the
attending physician (F504, F510). A report of findings for all laboratory,
radiology or special diagnostic services must be retained in the medical
record. When a report is received, a nurse must review the results, note
the findings, initial and date the report, and make an entry in the medical
record. The physician must be promptly notified of results of laboratory
findings (F505) and findings from radiology/other diagnostic services (F512).
If there are abnormal lab results but the physician decides not to treat,
a notation should be made in the medical record (i.e. nurses notes) documenting
the decision and reason.
6.15 Consents, Acknowledgements
6.15.1 Informed Consent for
Use of a Restraint:
(F221) When a
restraint is being considered for a resident, the facility must obtain
informed consent from the resident or their legal surrogate/representative.
The facility must explain the potential risks and benefits of using
a restraint, the risks and benefits of not using a restraint, and alternatives
to restraint all within the context of the residentís condition and
circumstances. Informed consent should include an explanation of how
the restraint would treat the residentís medical symptoms, assist the
resident in attaining/maintaining his or her highest practicable level
of physical or psychological well-being, and explain the negative outcomes
of restraint use.
6.15.2 Consent, Notice and
Authorization to Use/Release Clinical Records:
(F164) Prior to the release
of personal or clinical records an authorization must be obtained. See
section 4.9 on confidentiality and release of information.Under the
HIPAA final privacy rule, LTC facilities must obtain a Consent for Use
and Disclosure of Protected Health Information prior to delivery of
services. In addition to the consent, the facility must provide the
resident a written Notice of Privacy Practices. When information must
be disclosed outside of the scope of the consent form, the resident
or their legal representative must sign an authorization for to grant
the release. (The consent form covers disclosure for treatment, payment,
and healthcare operation purposes or when required by law.)
6.15.3 Notice of Bedhold Policy
(F205) The nursing facility
must provide written information to the resident and a family member
or legal representative that specifies the duration of the bedhold policy
under the state plan, if any, during which the resident is permitted
to return and resume residence in the nursing facility. The bedhold
policy is usually given to the resident and family/responsible party
at the time of admission. In addition, (F205) requires that the facility
provide a bedhold notice at the time of transfer.
6.15.4 Notice of Legal Rights
(F156) Prior to or upon
admission the facility must provide a written description of the residentís
legal rights and the items and services provided to the resident.
6.15.5 Notice Before Transfer:
(F203) Before a facility
discharges or transfers a resident, a notice must be given to the
resident or family member/responsible representative which includes:
- A copy of the facility bed hold policy
- The reason for transfer/discharge
- Effective date of transfer/discharge
- Location to which the
resident is transferred or discharged
- Statement that the
resident has the right to appeal the action to the state
- Name, address and telephone
number of the state long term care ombudsman
- For nursing facility
residents with developmental disabilities, the mailing address and
telephone number of the agency responsible for the protection and
advocacy of developmentally disabled individuals
- For nursing facility
residents who are mentally ill, the mailing address and telephone
number of the agency responsible for the protection and advocacy
of mentally ill individuals.
6.15.6 Notice prior to change
of room or roommate:
(F247) A notice must
be given to the resident prior to a change in room or roommate.
6.16 Advance Directives
(F155-156) The resident has
the right to formulate advanced directives. The facility must inform and
provide written information to all residents concerning the right to accept
or refuse medical or surgical treatment and, at the individualís option,
formulate an advance directive. A written description of the facilityís
policies to implement advanced directives and applicable state laws must
be provided to the resident or representative. A copy of the advanced directive
should be retained in the medical record.
6.16.1 DNR Order vs. Advance
Physician orders for a DNR
status should be consistent with the advance directives of the resident.
In the absence of a state law, the facility should obtain the residentís
advance directives prior to a code status/resuscitation order from the
6.17 Discharge Documentation:
6.17.1 Discharge Order:
(F202) The residentís physician
must document that a transfer or discharge is necessary. This documentation
is usually obtained via a physician order prior to discharge or transfer.
6.17.2 Discharge Note:
As a standard, a brief narrative
note should be written at the time of discharge, including the date
and time of discharge, the residentís disposition, where discharged
to, condition of the resident at discharge, and the individual taking
responsibility for the resident.
6.17.3 Discharge Summary:
(F283 and F284) For planned
discharges (i.e. discharges home or to another facility), federal regulations
require that the facility complete a recapitulation of the residentís
stay, a final summary of the residentís status based on the comprehensive
assessment, and a post-discharge plan of care. The post-discharge plan
of care serves as discharge instructions for a resident discharging home
or as the transfer form for a resident discharging to another health care
Minimum content for the post-discharge plan of care includes a description
of the resident and familyís preference for care, how the resident and
family will access the services, and how care should be coordinated if
continuing treatment involves multiple care givers. Specific resident
needs after discharge, such as personal care, sterile dressings, and therapy,
as well as a description of resident/care giver education needs to enable
the resident/care giver to meet needs after discharge.
6.17.4 Transfer Form:
As a standard, a transfer
form should be completed when transferring the resident to the hospital
or to another health care facility.
6.17.5 Physicianís Discharge
Summary vs. Discharge Record:
Federal regulations do not
require the completion of a physicianís discharge summary. State regulations
should be reviewed to determine the physicianís responsibility for documentation
upon discharge. At a minimum, a discharge record should be completed which
includes the date and time of discharge, disposition, final diagnoses
and where discharge location.