title: Quality variables for documentation in long-term care.
abstract: Documentation in long-term care clinical records continues to pose many challenges as the industry adjusts to a period of significant change. This article will look at some of the forces impacting documentation resulting from the first major federal rewrite in 15 years for long-term care facilities participating in Medicare and Medicaid. A short synopsis of the federal regulatory environment that reshaped the core content of the long-term care clinical record will be presented, as well as a discussion of related medicolegal issues, information technology issues, and similar topics affecting long-term care will have a better understanding of the multifaceted forces impacting documentation in the clinical record and thus recognize the importance of documentation as a key quality improvement opportunity for long-term care facilities.
authors.affiliation: College of St. Scholastica, Duluth, MN, USA.
authors.forename: T
authors.initials: T
authors.lastname: Ganser
mesh_terms: D000368:Aged; D014487:Centers for Medicare and Medicaid Services, U.S.; D004282:Documentation; D006707:Homes for the Aged / Q000331:legislation & jurisprudence / Q000592:standards*; D006801:Humans; D019451:Information Management / Q000379:methods*; D008134:Long-Term Care / Q000331:legislation & jurisprudence / Q000592:standards*; D008499:Medical Records / Q000592:standards; D011785:Quality Assurance, Health Care / Q000379:methods*; D014481:United States