Long Term Care Documentation Example-A Vital Component in Skilled Nursing

• Medicare is the primary insurance payer of most residents in skilled nursing, or long term care nursing. Medicare relies on proper detailed documentation in order to reimburse these types of nursing facilities. 
• Because these facilities rely so heavily on reimbursement for sustainability, documentation needs to be accurate and detailed. This type of documentation may be overwhelming to a new nurse, or a nurse new to these types of facilities. 
• This long term care documentation example will act as a guide for remembering what types of information needs to be recorded on a regular basis. 

One of my favorite roles thus far as a Licensed Practical Nurse has been my role of Charge Nurse at a long-term care facility. Although this is one of my most cherished memories as a nurse, the documentation that is required when working in long term care (LTC) was at times overwhelming and time consuming.  

Many nurses entering LTC are not aware of the amount of nurse documentation required of them or the details they must provide in their documentation.  

Nurse documentation is a vital part of caring for the elderly population. All nursing positions require a certain level of documentation; however, LTC is a little more in depth and detail focused to receive proper reimbursement for the services provided. Nursing notes are also legal documents and can be used in a legal case if questions arise about the care rendered.  

I wanted to write a long term care documentation example that is expected when working in LTC to help those nurses who are new to LTC who may be struggling with what needs to be entered into the resident’s chart.  

Each facility will have its own standards for nurse documentation. I have found that they are all similar to the long term care documentation example outlined below. 

Long Term Care Documentation Example

Admissions & Discharges

Document vitals and health status of the resident and any information surrounding the admission or discharge. 

Residents Who Leave Facility on Pass

Document the date and time resident left the facility and any medications that were sent with the resident. The facility is not responsible for anything that occurs outside their care. Make note when they return. 

Changes in Health Status

Document vitals, actions you took, any PRN (as needed) medications given such as Tylenol, Ibuprofen, or other pain medication the resident has ordered.  

Notify the physician and report the notification and any new orders. Notify the family or responsible party and document that as well.  

If the health status change required an emergency room transfer be sure to get an order for the transfer and document the time the resident was transferred to the emergency room for evaluation.  

Record whether they were admitted to the hospital or when they returned to the facility. Enter in any new orders they receive while gone. 

Skin Tears & Bruising

Document new skin tears or bruises and their location on the resident. Try to discover origin of the tears or bruises.  

It is important to document the size and appearance of the injuries as well. Contact physician and family if needed and document. Log any application of dressings, Steri-strips, or ointment.  

New Orders

If a resident was seen during provider rounds and given any new medicaition or treatment orders, document those in the resident’s chart. Notify family and document notification.

Falls

Document every fall. Alert the physician and family and document notification. Document any new orders and if the fall warranted a visit to the emergency room. 

Resident Refusals or Behaviors

Document anytime a resident refuses a medication, shower, meal, etc. Also document any behavior that is unusual for the resident. May also require notification of physician and family, document notification. If resident declines after refusals the nurse notes will prove the healthcare team is aware of the refusals.  

Administration & Response to PRN Medications

Document vitals, actions you took, any PRN (as needed) medications given such as Tylenol, Ibuprofen, or other pain medication the resident has ordered.  

Notify the physician and report the notification and any new orders. Notify the family or responsible party and document that as well.  

Lab Results

Inform physician and family of abnormal lab values and document. Log any new orders received as a result of the lab values.  

Medicare Charting

If the resident’s main payor is Medicare they usually require documentation in the resident’s chart every twenty-four hours. They may also require documentation each shift. Document vitals, health status, and why the resident is receiving services. 

As you can see, there is a lot of charting and documentation involved in the care of an elderly resident. I hope this long term care documentation example will assist in remembering the types of things you need to document when working in LTC. 

The Bottom Line

Working as a nurse in LTC can be particularly challenging but rewarding as well. One should not let the documentation steer one away from this area of nursing.  

Being required to document regularly will only grow your skills and confidence with nurse documentation. The more you do it the easier it will get. 

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