Lesson 1, Topic 1
In Progress

Long-Term Health Care Documentation

May 1, 2021

An ever-increasing number of older adults need care in long-term health care facilities. Because many individuals live in this setting for the rest of their lives, they are referred to as residents rather than as patients. The acuity of residents’ conditions, and the number of their disabilities, continues to escalate commensurate with their age. Nursing personnel often face challenges much different from those in the acute care setting. These differences establish a significantly different basis for nursing documentation.

Outside agencies are instrumental in determining the standards and policies for documentation in long-term health care. For example, the Omnibus Budget Reconciliation Act (OBRA) of 1987 instituted extremely significant Medicare and Medicaid requirements for long-term care provision and documentation. Among the requirements of OBRA are minimum data sets (MDS) and regulated standards for resident assessments, individualized care plans, and qualifications for health care providers (RNs and LPN/LVNs). In addition, the department of health in each state governs the frequency of the required nursing entries in the records of residents in long-term care facilities. Long-term care documentation supports a multidisciplinary approach in the assessment (referred to as the MDS) and the planning process (referred to as resident assessment protocols) of the residents. Often, long-term care agencies also have skilled care units where patients or residents stay when, in response to mandates for shorter hospital stays, they need increased levels of care and are not able to return directly to their usual residence after a hospital admission. Multidisciplinary communication among such health care providers as nurses, unlicensed assistive personnel (UAP), social workers, physical therapists, and dietitians is essential in the regulated documentation process. The fiscal management of long-term care hinges on the justification of nursing care as demonstrated in sound documentation of the services rendered. Additional documentation information in long-term care is discussed in Chapter 37.