Why is daily charting necessary and how do you tackle compliance with Medicare A charting?



Documentation is an important part of providing resident care, it is a means to facilitate communication among the healthcare team, allowing for collaboration and informed decision making. Documentation is central to Quality of Care, serving as a tool to monitor the residents’ condition and evaluate outcomes, communicate with other caregivers, and as a legal record to justify clinical care and services. Documentation  is a requirement for providers to be appropriately reimbursed for the services they provide.

Although the specific documentation required by payor source may vary, the overall goal of charting is to capture  the resident’s condition, care and services provided,  and response to treatment. For residents staying at your facility under their Part A Medicare benefit, chapter 8 “Coverage of extended care services (SNF) under hospital insurance”, of the Medicare Benefit Policy Manual describes documentation guidelines that must be followed.

Ensuring compliance with documentation requirements can be challenging. Consider these tips to drive compliance in your facility:

  1. Help staff to understand the “why” of documentation compliance
  2. Provide a template for nurses to follow that outline the necessary elements
  3. Implement training and maintain systems that facilitate nurses understanding of the Nursing CMG under PDPM and their role in charting the skilled services being provided related to the conditions being treated
  4. Integrate nursing and therapy skilled services through regular Medicare/Utilization Review processes which may include regular meetings
  5. Routinely monitor documentation as part of the QA process to validate compliance with regulatory requirements and facility policies and procedures related to documentation.
  6. If you are finding an individual is having issues completing their charting or not doing it correctly, provide education and feedback to that person. Maintain accountability for accurate and timely charting and the prompt resolution of errors.
  7. If you are finding systemic issues with Medicare supportive documentation, utilize the QAPI program to assess and resolve these issues
  8. Always encourage a culture of transparency that encourages staff to reach out with questions


Nancy Casperd, BSN, RN, CHC
Clinical Consultant

Was this article helpful? Access weekly insights when you sign up for our weekly newsletter!