Medicare charting - HealthInsight



Medicare charting- Daily charting as designated per AM or PM shifts. Include assist w/ADL’s, and teaching) 12/04

|PAIN MANAGEMENT |PNEUMONIA/CHF/COPD |MI/HEART CONDITIONS |TUBE FEEDING |

|1). Pain characteristics/level |1). Lung sounds |1). Apical pulse, check |1). Tolerance to feeding |

|2). Document effectiveness of |2). 02use |peripheral also if needed |2). Amount of intake, fluids |

|scheduled analgesics. |4). 02 saturation |2). Chest pain |and nutrition on flow sheet |

|3). Use of prn analgesics and |5). Activity tolerance |3). Activity intolerances |3). Site appearance |

|effectiveness |6). Sputum characteristics if |4). NTG use |4). Oral intake |

|4). Non-pharmacologic pain interventions ie: ice, |applicable |5). Orthostatic B/P if applicable |5). Residuals, check tube |

|cryco cuff, heat, elevation of effected extremity. | | |placement prior to feeding |

|5). Teaching |DIABETES |GI BLEED/ANEMIA |6). Bowel sounds |

| |1). Blood sugars charted & MAR |1). Blood noted in emesis or |7). Swallowing ability (able to |

|POST SURGERY |2). Injections and amount of |stool, guiac |handle oral secretions) |

|1). Incision site and treatment, |sliding scale insulin used |2). Activity intolerance |8). Teaching to resident or |

|any drainage noted, edema |3). Diet compliance |3). Skin and temp color |family |

|2). Pain r/t incision site |4). Hypo or hyper glycemic events |4). Appetite | |

|3). Bowel pattern |and treatment used for them. |IV’s |UTI |

|4). Signs of infection |5). Teaching |1). Monitor site appearance |1). Continence |

| | |2). Dressing changes |2). Urine characteristics |

|FRACTURE |CVA |3). Dosage administration |3). S/S of UTI ie: burning, |

|1). Pain |1). Speech |4). Flushing |urinary frequency, increased |

|2). Skin temp and appearance |2). Swallowing | |confusion, elevated temp, |

|3). CMS checks |3). Cognition |CONFUSION |abdominal or back pain, |

|4). Edema |4). ADL’s |1). Cognition |foul odor noted to urine. |

|5). Brace /cast use |5). Hemiparesis |2). Memory | |

|6). Compliance with WB status | |3). Ability to follow directions |MD/GNP |

| |FLUID/ELECTROLYTE IMABLANCE |4). Anxiety |1). Chart when call and when |

|PRESSURE AREAS/WOUNDS |1). Signs of dehydration | |get return call. |

|1). Appearance of area and |2). Weight changes |CANCER | |

|location, drainage, granulation |3). Edema |1). Treatment and tolerance to |LABs |

|tissue present |4). Skin turgor |2). Appetite |1). Chart when called and when |

|2). Treatments and tolerance |5). Appetite |3). Pain |get return call. |

|3). Pain |6). Bowel pattern |4). Activity tolerance | |

|4). Signs of infection |7). Heart rate and pattern |5). Ability to do therapies | |

|5. Stage of pressure wound |8). I&O if applicable |6). Skin condition | |

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