Long Term Care Documentation

• 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