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Long Term Care Documentation

Long Term Care Documentation

Long Term Care Documentation

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• Review the information sent with the patient

• Interview the staff on how the patient has done since

admission

• Review any labs and radiographs

• AFTER THIS, then begin to document your note

• Start with MDM first


• Students are ONLY allowed to document in the

following sections

• Past Family, Medical, Social History

• Review of Systems

• Medication List

• Flowsheets

• No other documentation by students on the billed bll record is allowed per federal regulations


• Two Page Initial H&P

• One Page Followup Note


Document NH location and whether patient

is in SNF, NF or Hospice. Ask

attending for help if you need it.


Document HPI in Box

Note: Severity

& Length of each

illness should be included

Example: “78 yo woman with

long standing, moderate HTN”


Document if you reviewed

prior hospital records

here


Document from either family

or prior records.

Include Advance Directives!


The review of systems you did

is recorded here.

If the pt is unable to answer ROS

then line thru this section and put

reason in HPI

(dementia, aphasia, etc.)


Leave Room for the Attending Signature


On every note document NH

location & Service Type

H&P date needs to

be documented here

on ALL notes!


• Ask an Attending

• Ask our long term

care coordinator at

568‐5600

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