DOCUMENTATION

PURPOSE:

To ensure that all documentation is timely and reflects quality care which meets or exceeds the New Jersey Department of Health and US Veterans Affairs Standards.

PROCEDURE:

All clinical notes must incorporate written signed and dated notations by each member of the health care team who provides services to the resident, including a description of signs and symptoms, treatments and/or drugs given, the resident's reaction and any changes in physical or emotional condition when the service was provided. All documentation within a Medical Record must be completed within the time frame specified by the New Jersey Department of Health and US Veterans Affairs Standards.

I. Physician

A. Medical Care Plan

1. Skilled
- completed upon admission
- minimum every thirty days, and as needed.

2. ICF-A
- completed upon admission
- every thirty days

3. ICF-B
- completed upon admission
- every sixty days

B. History and Physical

All Levels of Care
- completed upon admission
- annually

C. Physician Orders

All Levels of Care
- every thirty days

D. Physician Progress Notes

1. Skilled and ICF-A
- minimum every thirty days, and as needed

2. ICF-B
- every thirty days

II. Nursing

A. Charting Schedule

1. Skilled

- weekly - charting on new admissions must be done on every shift for the first five days. At the end of five days, the records must be updated once a week.

2. ICF-A

- every two weeks - charting on new admissions must be done every shift for the first five days. At the end of five days, the records must be updated once a week for the next four weeks. After the resident's first five weeks in the facility, the Medical Record is to be updated every two weeks.

3. ICF-B

- every thirty days - charting on new admissions must be done on every shift for the first five days. At the end of five days, the records must be updated once a week for the next four weeks. After the resident's first five weeks in the facility, the Medical Record is to be updated every thirty days.

B. Monthly Summary Schedule

1. Skilled and ICF-A
- every thirty days

2. ICF-B
- every sixty days

C. Resident Care Plan

All Levels of Care
- updated when Monthly Summary is completed

D. Charting of Vital Signs

All Levels of Care
- every thirty days

III. Social Service

A. Patient Care Plan

All Levels of Care
- completed upon admission
- updated every six months

IV. Activities/Recreation

A. Patient Care Plan

All Levels of Care
- completed upon admission
- updated every three months

V. Pharmaceutical Consultant

A. Charting Schedule

All Levels of Care
- every thirty days

VI. Dental Service

All Levels of Care
- annually
- initial evaluation done within six months of admission

VII. Podiatrist

A. Charting Schedule

All Levels of Care
- initial assessment done on admission
- every sixty days

VIII. Dietary

A. Charting Schedule

All Levels of Care
- every thirty days

B. Patient Care Plan

All Levels of Care
- completed upon admission
- Short Term Goals: updated every three months
- Long Term Goals: updated every six months

IX. Rehabilitation

A. Physical Therapy and Occupational Therapy

1. Charting Schedule

All Levels of Care
- each time the resident receives therapy

2. Monthly Progress Summary

All Levels of Care
- every thirty days

3. Patient Care Plan

All Levels of Care
- updated every thirty days

X. Transferred Residents

All Levels of Care

- Residents discharged from the facility beyond thirty days require a comprehensive discharge summary from every department that provided the resident with care. - Residents discharged beyond thirty days will have a new chart initiated. The chart number is to remain the same except for a code letter to be added indicating the number of hospital admissions.

MEDICAL RECORDS  - 35-03-007

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