This resource provides PDPM Skilled Nursing Charting Guidelines for condition/service specific NTA items and by Clinical Category with actual skilled documentation examples.
1) PDPM Clinical Category Skilled Nursing Documentation Guidelines
This 4-page table provides both General SNF Skilled Documentation Guidelines and Guidelines for each PDPM Clinical Category. A listing of recommended daily documentation considerations as well as a sample note is provided for each PDPM Clinical Category including Acute Infections, Acute Neurologic, Cancer, Cardiovascular & Coagulations, Major Joint Replacement or Spinal Surgery, Medical Management, Non-Orthopedic Surgery, Orthopedic Surgery, and Pulmonary
2) PDPM Condition Specific/NTA Skilled Nursing Documentation Guidelines
This 11-page resource provides condition and/or service specific skilled nursing documentation guidelines including daily documentation guidance and a sample note for each condition. Conditions include: Enteral feeding, Pneumonia/Asthma/COPD/Chronic Lung Disease, CVA, Wound/Wound Infection/Diabetic Foot Ulcer/Surgical Wound/Open Lesion, Diabetes, UTI, HIV/AIDS, IV Feeding, IV Medications, Ventilator, Lung Transplant, Other Major Organ Transplant, Multiple Sclerosis, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis, Chronic Myeloid Leukemia, Endocarditis, End-Stage Liver Disease, Narcolepsy & Cataplexy, Cystic Fibrosis, Tracheostomy, Multi-Drug Resistant Organism, Isolation, Immune Disorders, Morbid Obesity, Radiation, Psoriatic Arthropathy & Systemic Sclerosis, Chronic Pancreatitis