Medicare Charting Guideline

Patient Details:

• Resident Name:
• Date of Admission:

Admitting Diagnosis:

• Main Diagnosis:
• Other Diagnoses:

Reason for Skilling on Medicare:

• Physical Therapy:
• Occupational Therapy:
• Speech Therapy:
• Respiratory Therapy:
• Anticoagulation Therapy:
• Medication/Order Changes:
• Neurological Vital Signs:
• Type and Location of IV Site:
• ADL and Mobility Status:
• Fluid Intake and Output:
• Temperature Monitoring:
• Pain Assessment and Response to Treatment:
• Nutritional Status and Dietary Intake:
• Genitourinary/UTI Monitoring:
• Cough or Pulmonary Congestion:
• Enteral Feeding Details:
• Wound Care and Surgical Wounds Monitoring:
• Fractures and Orthopedic Follow-up:
• Chemotherapy or Radiation Therapy:
• Neurological Assessment:
• Stoma Site and Condition:
• Colostomy/Ileostomy Care:

Specific Assessments and Interventions:

• Cardiovascular Compromise Assessment:
• Gastrointestinal Complication Monitoring:
• Dehydration/Malnutrition Evaluation:
• Circulation Problems Assessment:
• Isolation Monitoring:
• Hemodialysis Details (if applicable):
• Medically Unstable Condition Assessment:
• Gastrointestinal Evaluation:
• Diabetes and Insulin Management:
• Injections and Catheterization Monitoring:

Ongoing Observations and Documentation:

• Vital Signs Post Treatment:
• Presence/Absence of Drainage or Odor:
• Weights and Changes:
• Orthopedic Follow-up Details:
• Educational/Teaching Interventions:
• Skilled Therapy Involvement:
• Patient Safety Concerns and Interventions:
• Patient Communication and Understanding:
• Monitoring Responses to Therapies or Medications:
• Clinical Education and Teaching Notes:

Updates and Additional Notes:

• (Include space for updated clinical practices or specific notes relevant to the patient's care.)