Director of Nursing Manual

For Health Care Facilities

Checklist for Determining Medicare Coverage

Overall Management and Evaluation of Care Plan

Note: This constitutes skilled services when the Development, Management, and Evaluation of the care plan based on Physician’s orders require the involvement of technical or professional personnel in order to meet needs, promote recovery, and ensure medical safety. Activities may be personal care, but in light of the beneficiary’s total condition, these activities in aggregate require a technical or professional staff daily to manage plan.

Observation and Assessment of Changing Condition

Note: Observation and Assessment constitutes skilled services when the skills of a technical or professional person are required to identify and evaluate the patient’s need for modification of treatment or for additional medical procedures until condition is stabilized.

Neurological Services
  1. Level of consciousness-responds to verbal/painful stimuli
  2. Pupil size, reaction
  3. Movement/weakness
  4. Seizure activity
/ Respiratory
  1. Shortness of breath
  2. Dyspnea, cyanosis
  3. Lung sounds, rales, rhonchi, wheezing
  4. Productive cough, thick, copious sputum
  5. Respiration, depth, and rate

Cardiac
  1. Pulse, rate, rhythm
  2. Peripheral edema
  3. Chest pain
  4. Lung sounds
  5. Medication-adverse reactions and/or adjustments
  6. Rapid weight gain
  7. Cyanosis
/ Gastrointestinal
  1. Nausea, vomiting
  2. Diarrhea
  3. Bowel sounds
  4. Distention
  5. Sudden weight loss
  6. Gastric pain
  7. Hemocult (stools)

Circulatory
  1. Pedal pulse
  2. Color, warmth of extremity
  3. Capillary refill
  4. Edema
  5. Pain/numbness/tingling
/ Surgical
  1. Incision site signs and symptoms of infection, approximation

Genitourinary
  1. Urinary tract infection-burning, frequency, hematuria, pain and fever
/ Medications
  1. Adverse side effects and dosage adjustment
  2. Electrolyte imbalance due to medication therapy
  3. Coumadin -presence or absence of symptoms
  4. Antibiotic therapy
  5. Steroid therapy (new or with adjustments)
  6. Chemotherapy-monitor nausea, vomiting, fever, ulceration
  7. Pain management- frequency, side effects, effectiveness
  8. Psychotropic medications, adjustments monitor therapeutic
  9. Effects

Dehydration/Malnutrition / Isolation (Precautions)
Laboratory
Skilled Nursing Services: / IV/IM Injections/Continuous Sub-Q Pump
  1. Heparin
  2. Antibiotics
  3. Pain medications
  4. Other (Excludes subcutaneous injections)

Tube Feedings (N/G, GT, or Jejunostomy)
  1. Meet calorie and fluid requirements
/ Stage III or IV Pressure Sores
Wound Care/Dressing
  1. With prescription and aseptic technique
/ Respiratory Treatments
  1. Suctioning (Nasopharyngeal and trach)
  2. Initial phases of a regimen involving administration of medical gases
  3. Oxygen therapy

Urological
  1. Supra-pubic catheter insertion or irrigation
/ Intravenous Therapy or Feeding
Heat Treatment
  1. Physician orders, nurse needed to monitor progress

Rehabilitation Services:

Need both #1 and #2 to qualify
Requires skills of a licensed therapist 5 days a week. Can be a combination of therapy (i.e. Physical, occupational, or speech). Note: Goal is to improve patient’s functional ability.
Requires skills of licensed therapist
Requires whirlpool for stage III or IV Pressure Sore or burns (for purpose of cleaning/draining wound or debridement)

Patient Education Services:

If YES is noted on any item below, the beneficiary is skilled for Patient Education
Self-administration of an injectable medications or a complex range of medications
Self-Administration of insulin injections, to prepare and follow a diabetic diet, and observe foot care
Self-Administration of Medical Gases
 Gait training and Prosthesis care
Care for a recent Colostomy and Ileostomy
Self-Catherization and self Administration of Gastronomy Feedings
Care and maintenance of central venous lines, such as Hickman Catheters
Use and care of Braces, Splints, and Orthotics and any associated skin care
Care of any specialized dressings or skin treatments

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Director of Nursing Manual 2008