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Covers routine visit documentation quality (poor vs good examples), routine supportive documentation, and the elements of effective documentation such as accurate terminology, authorized abbreviations, charting promptly, and documenting responses to teaching and interventions. Details general requirements including infections, medication dosing and patient response, treatment refusals, and “as evidenced by” phrasing, plus RN/LPN care plan and medication updates aligned with condition changes.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":51,"@type":70,"position":76},"https://docshare.wps.com/template/general/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/documentation-and-scales-routine-documentation-orientation-handbook/572291/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/documentation-and-scales-routine-documentation-orientation-handbook/572291.png","ImageObject",442,249,{"name":88,"@type":89},"aboduw","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-20","2026-10-13",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What should documentation include during routine documentation?","Question",{"text":108,"@type":109},"Documentation should include clinical findings such as vital signs and weight change, interventions provided and the beneficiary/family response, teaching and communication with facility and POA/family, the course of the terminal illness, and interventions consistent with the plan of care.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How should descriptors like weight loss or non-ambulatory be documented?",{"text":113,"@type":109},"When using descriptors such as cachectic, anorexic, non-ambulatory, dyspnea, weight loss, poor appetite, or fragile, always follow with “as evidenced by” and describe the observable evidence supporting the descriptor.",{"name":115,"@type":106,"acceptedAnswer":116},"What are key RN/LPN documentation requirements for care plans and medications?",{"text":117,"@type":109},"Care plans must be reviewed weekly, updated and annotated when the patient condition changes, and resolved when issues are no longer active. Medications must be up to date and match the facility POS, with new medications entered and discontinued ones removed each visit, including dose, route, frequency, and purpose.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},572291,1792455692,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":50,"category_name":51,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":45,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":140},3985747862266,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","DOCUMENTATION AND SCALES  \nROUTINE DOCUMENTATION  \n• Documentation should include:  \n• Clinical findings describing vital signs, weight loss/gain, fevers, wound status, etc…  \n• Interventions provided and the response of the beneficiary and family.  \n• Teaching, communication and collaboration with facility and POA/Family.  \n• The course of the terminal illness.  \n• Interventions that are consistent with the plan of care.  \n1. ROUTINE VISIT DOCUMENTATION  \n• POOR DOCUMENTATION  \n• Diagnosis of dementia. Weight is 100 lbs. Poor appetite. Sleeps a lot. Has had past infections.  \n• GOOD DOCUMENTATION  \n• Hospice Diagnosis is Dementia, KPS: 40, FAST: 7D from 7A, PPS: 40%, Unable to make needs known and speech is nonsensical. Incontinent of bowel and bladder, cannot ambulate, and remains bed/chair bound. Weight loss of 15 lbs in the last 2 months, remains on honey thickened liquids and needs total assist with feeding and all other ADLS. Appetite is now poor. Three UTI’s treated in last 6 months  \n2. ROUTINE SUPPORTIVE DOCUMENTATION  \n• ROUTINE VISIT  \n• Has poor appetite: eating 3-4 bites of food with difficulty as evidenced by pocketing of food. Eating an avg. of 25-50% of meals, drinks 2-3 sips of liquids coughing noted.  \n• Current weight of 100 lbs, weight loss of 15 lbs in 2 months. BMI 19.5 (May weight 115 lbs, June 106 lbs)  \n• April 2013 hospitalized for pneumonia and treated with IV Antibiotics.  \nELEMENTS OF EFFECTIVE DOCUMENTATION  \n• Make sure spelling of all terms is accurate.  \n• When checking boxes, make certain they are accurate.  \n• Chart visit immediately if possible.  \n• Document the patient/caregiver/family’s response to teaching and other interventions.  \n• Only use authorized abbreviations.  \nGENERAL DOCUMENTATION REQUIREMENTS  \n• Infections within the past 12 months.  \n• Details of medication(dosage, route, frequency), and the patients response.  \n• Refusals of treatment, medication, therapy, etc… Document refusals to physician and all appropriate disciplines .  \n• Good to include repeating past observations that were evident of the patient’s decline (i.e. recent hospitalizations, decreased tolerance to ADLs, etc) .  \nGENERAL DOCUMENTATION REQUIREMENTS – “AS EVIDENCED BY”  \n• ANYTIME ONE USES DESCRIPTORS SUCH AS:  \n• Cachectic, anorexic, non-ambulatory, dyspnea (at rest or on exertion), weight loss, poor appetite, fragile, agitated, weaker etc…  \n• Always follow up with “as evidenced by…” to fully describe what is seen:  \nExample: “Patient appears tachypnic as evidenced by respiratory rate of 32 and use of accessory muscles.”  \nDOCUMENTATION FOCUS  \nHOSPITAL  \n• Focus on what patient can achieve  \n• Curative treatment  \n• Documentation reflects a positive outcome  \nHOSPICE  \n• Focus on what patient cannot achieve  \n• Palliative treatment  \n• Documentation reflects a negative outcome.  \nSHIFT YOUR FOCUS FROM CURATIVE TO PALLIATIVE.  \nDOCUMENTATION REQUIREMENTS  \n•  RN/LPN-CARE PLAN PROBLEMS  \n• Care plans need to be reviewed weekly.  \n• Related care plans should also be changed, updated and notes added when there is a change in the patient’s condition. (For example when a patient is diagnosed with a UTI, the care plan should be updated with a note entered) .  \n• When the issue has resolved the care plan should be resolved. Only care plans that should be open are ongoing issues.  \nDOCUMENTATION REQUIREMENTS  \n•  RN/LPN-MEDICATIONS  \n• Medications need to be up to date and match the facility POS. Make sure to enter new medications and discontinue old medications at each visit.  \n• Entering Meds:  \n• Include: Dose, Route, Frequency and  \nPURPOSE  \n• EXAMPLE: Albuterol 1 vial neb q 4hrs PRN for periodic SOB.– What’s it treating?","cbCainrjzu2sXEkY","https://ap.wps.com/l/cbCainrjzu2sXEkY","pdf",427890,"English","# Documentation and Scales\n## Routine Documentation\n### Routine Visit Documentation\n### Routine Supportive Documentation\n## Elements of Effective Documentation\n## General Documentation Requirements\n### As Evidenced By\n## Documentation Focus: Hospital vs Hospice\n## Documentation Requirements for RN/LPN\n### Care Plan Problems\n### Medications","[{\"question\":\"What should documentation include during routine documentation?\",\"answer\":\"Documentation should include clinical findings such as vital signs and weight change, interventions provided and the beneficiary/family response, teaching and communication with facility and POA/family, the course of the terminal illness, and interventions consistent with the plan of care.\"},{\"question\":\"How should descriptors like weight loss or non-ambulatory be documented?\",\"answer\":\"When using descriptors such as cachectic, anorexic, non-ambulatory, dyspnea, weight loss, poor appetite, or fragile, always follow with “as evidenced by” and describe the observable evidence supporting the descriptor.\"},{\"question\":\"What are key RN/LPN documentation requirements for care plans and medications?\",\"answer\":\"Care plans must be reviewed weekly, updated and annotated when the patient condition changes, and resolved when issues are no longer active. Medications must be up to date and match the facility POS, with new medications entered and discontinued ones removed each visit, including dose, route, frequency, and purpose.\"}]","Documentation and Scales - Routine Documentation - Orientation handbook | PDF",1791926594,7]