Biomaterial Database

New clinical documentation guidelines for long-term care. 1988

J Micheletti, and T J Shlala

Nursing homes are becoming subject to more stringent rules and regulations regarding documentation of care given and can expect closer monitoring of their facilities. This article discusses evolving long-term care clinical documentation initiatives, suggests guidelines and offers recommendations to help cope with the requirements.

UI	MeSH Term	Description	Entries
D008134	Long-Term Care	Care over an extended period, usually for a chronic condition or disability, requiring periodic, intermittent, or continuous care.	Care, Long-Term,Long Term Care
D008484	Medicaid	Federal program, created by Public Law 89-97, Title XIX, a 1965 amendment to the Social Security Act, administered by the states, that provides health care benefits to indigent and medically indigent persons.	Dental Medicaid Program,Medical Assistance, Title 19,Dental Medicaid Programs,Medicaid Program, Dental,Medicaid Programs, Dental,Program, Dental Medicaid,Programs, Dental Medicaid
D008499	Medical Records	Recording of pertinent information concerning patient's illness or illnesses.	Health Diaries,Medical Transcription,Records, Medical,Transcription, Medical,Diaries, Health,Diary, Health,Health Diary,Medical Record,Medical Transcriptions,Record, Medical,Transcriptions, Medical
D009735	Nursing Homes	Facilities which provide nursing supervision and limited medical care to persons who do not require hospitalization.	Homes, Nursing,Nursing Home
D011366	Professional Review Organizations	Organizations representing designated geographic areas which have contracts under the PRO program to review the medical necessity, appropriateness, quality, and cost-effectiveness of care received by Medicare beneficiaries. Peer Review Improvement Act, PL 97-248, 1982.	PRO Professional Review Organizations,PSRO,Peer Review Organizations,Professional Standards Review Organizations,Utilization and Quality Control Peer Review Organizations,Organizations, Peer Review,Organizations, Professional Review,Review Organizations, Professional,Organization, Peer Review,Organization, Professional Review,Peer Review Organization,Professional Review Organization
D003953	Diagnosis-Related Groups	A system for classifying patient care by relating common characteristics such as diagnosis, treatment, and age to an expected consumption of hospital resources and length of stay. Its purpose is to provide a framework for specifying case mix and to reduce hospital costs and reimbursements and it forms the cornerstone of the prospective payment system.	Case Mix,DRG,Diagnosis Related Group,Diagnosis-Related Group,Case Mixes,DRGs,Diagnostic-Related Group,Group, Diagnostic-Related,Groups, Diagnostic-Related,Diagnosis Related Groups,Diagnostic Related Group,Diagnostic-Related Groups,Group, Diagnosis Related,Group, Diagnosis-Related,Group, Diagnostic Related,Groups, Diagnosis Related,Groups, Diagnosis-Related,Groups, Diagnostic Related,Related Group, Diagnosis,Related Groups, Diagnosis
D004282	Documentation	Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information.	Documentations
D014481	United States	A country in NORTH AMERICA between CANADA and MEXICO.