Course Content
Module 1 — Medication Administration / MAR / TAR Documentation
Frequency: Upon hire and annually
0/1
Medication Administration / MAR / TAR Documentation
Module 2 — Change of Condition / SBAR / Physician Notification
Frequency: Annual
0/1
Change of Condition / SBAR / Physician Notification
Module 3 — Skilled Documentation for Medicare Residents
Frequency: Annual
0/1
Skilled Documentation for Medicare Residents
Module 4 — Wound Assessment and Pressure Injury Prevention
Frequency: Annual
0/1
Wound Assessment and Pressure Injury Prevention
Module 5 — Fall Assessment and Neuro Checks After Fall
Frequency: Annual
0/1
Fall Assessment and Neuro Checks After Fall
Module 6 — Pain Assessment and Pain Management
Frequency: Annual
0/1
Pain Assessment and Pain Management
Module 7 — Anticoagulants, Insulin, Opioids, and High-Risk Medications
Frequency: Annual
0/1
Anticoagulants, Insulin, Opioids, and High-Risk Medications
Module 8 — Controlled Substance Handling and Reconciliation
Frequency: Annual
0/1
Controlled Substance Handling and Reconciliation
Module 9 — Psychotropic Medications and Gradual Dose Reduction
Frequency: Annual
0/1
Psychotropic Medications and Gradual Dose Reduction
Module 10 — Infection Surveillance and Antibiotic Stewardship
Frequency: Annual
0/1
Infection Surveillance and Antibiotic Stewardship
Module 11 — UTI Criteria, Respiratory Infection, and Sepsis Recognition
Frequency: Annual
0/1
UTI Criteria, Respiratory Infection, and Sepsis Recognition
Module 12 — Tube Feeding / G-Tube Care
Frequency: Competency on hire and annually
0/1
Tube Feeding / G-Tube Care
Module 13 — Oxygen Safety and Respiratory Care
Frequency: Annual
0/1
Oxygen Safety and Respiratory Care
Module 14 — IV Therapy / PICC / Midline Care
Frequency: Competency before assignment
0/1
IV Therapy / PICC / Midline Care
Module 15 — TPN Training
Frequency: Competency before assignment if facility accepts TPN residents
0/1
TPN Training
Module 16 — Dialysis Resident Care
Frequency: Competency before assignment if accepting hemodialysis residents
0/1
Dialysis Resident Care
Module 17 — Hospice, Palliative Care, and Comfort Medications
Frequency: Annual
0/1
Hospice, Palliative Care, and Comfort Medications
Module 18 — Advance Directives, DNR, POLST, and Code Status
Frequency: Annual
0/1
Advance Directives, DNR, POLST, and Code Status
Module 19 — Incident Investigation and Root-Cause Documentation
Frequency: Annual
0/1
Incident Investigation and Root-Cause Documentation
Private: Nurse RN/LPN Training

Skilled documentation must show why the resident requires skilled nursing or skilled rehabilitation services, what skilled intervention was provided, how the resident responded, and why continued skilled care is medically necessary. CMS Medicare Benefit Policy Manual Chapter 8 addresses SNF coverage of extended care services and skilled service requirements.

Strong Skilled Note Should Include

  • Skilled reason for the note: wound care, IV therapy, complex medication monitoring, respiratory care, post-hospital monitoring, new diagnosis, infection, pain management, tube feeding, diabetes instability, anticoagulant monitoring, etc.
  • Objective findings: vitals, wound measurements, intake/output, pain scale, lung sounds, edema, blood glucose, oxygen saturation, mental status.
  • Skilled intervention performed.
  • Resident tolerance and response.
  • Teaching provided to resident/family.
  • Communication with provider/therapy/pharmacy/dietary.
  • Plan for continued monitoring.

Avoid Weak Documentation

Avoid vague phrases such as “resident stable,” “no complaints,” or “continue to monitor” without clinical detail.

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