Documentation Fundamentals
When should you document care?
Immediately after it’s provided — never before.
What are the “5 Rights” of medication administration?
Right resident, right drug, right dose, right route, right time.
What does Medicare use charting to verify?
That skilled services were medically necessary and provided daily.
What’s the difference between a late entry and falsification?
Late entry = truthful documentation after the fact; falsification = false or misleading entry.
During survey, how should you answer if asked, “When do you document?”
“Right after care is given, accurately and completely.”
What’s the golden rule of documentation?
If it’s not documented, it wasn’t done.
What should be documented after giving each medication?
Time, dose, route, and any resident reaction.
What is a “skilled service” under Medicare?
A service that requires professional nursing or therapy judgment (e.g., wound care, IVs, rehab).
How long must Medicare records be retained?
Typically 7 years (varies by state and payer).
What’s one red flag for surveyors reviewing charts?
Blank sections or copy-paste notes that don’t match the resident’s condition.
What’s the difference between objective and subjective charting?
Objective: factual observations; Subjective: resident’s reported feelings or statements.
What do you document for a PRN medication?
Reason given, time, and resident’s response.
What phrase must be reflected in skilled notes?
Resident’s progress, response to treatment, and continued skilled need.
Who owns the medical record?
The facility, but the resident has the right to access it.
What should be included in Medicare daily skilled documentation?
Skilled task performed, assessment, resident response, and next plan of care.
What should every note include?
Date, time, care provided, resident response, and your initials/signature.
What’s the acceptable medication pass window?
30 minutes before or after the scheduled time.
Why must nurses and therapists document daily?
Medicare requires evidence of ongoing skilled intervention for reimbursement.
What federal law governs false claims or billing for undocumented services?
The False Claims Act.
How do QAPI and documentation connect?
Accurate charting identifies patterns, guides improvement, and prevents repeat errors.
Why is accuracy in charting essential beyond resident care?
It drives survey outcomes, Quality Measures, and reimbursement.
What should you do if a medication is refused or held?
Document refusal/hold, reason, and notify the nurse or physician as required.
What happens if skilled charting doesn’t support continued need?
Medicare may deny or stop coverage — the facility could lose payment.
What can happen if skilled documentation is incomplete or inaccurate?
Denial of claims, loss of revenue, and potential legal penalties.
Why is interdisciplinary communication key in Medicare charting?
Therapy, nursing, and MDS must align so PDPM and billing match clinical reality.