This resource provides PDPM Skilled Nursing Charting Guidelines for condition/service specific NTA items and by Clinical Category with actual skilled documentation examples. Include these PDPM Charting Guidelines as part of your skilled nursing education to promote quality documentation to support the nursing care and services provided.
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