Re: Quarterly Notes

[edart6]

ï If there are no notes (and in our charts there are frequently none, also, if the resident has been stable, with no accidents, ulcers, skin tears, etc.), then we have to interview staff and observe the resident to obtain the lookback ADL's. Other disciplines would have to do the same process to obtain the needed information. If all information was gleaned through interview/direct observation, then we write notes indicating the results of the interviews and observations. Good luck!   On Fri, 5 Dec 2003 15:10:11 EST [EMAIL PROTECTED] writes: We are having a problem at my new facility and your input would really help.   When I do a quarterly MDS  or any MDS for that matter there is not enough documentation.  An example would be  doing a quarterly note with only 1 progress note in 3 months and CNA records half filled out. How do you handle these situations? I spoke with the head of my department on the corporate level who tells me to go and do a full assessment my self and do a late entry for the ARD. I do not feel confortable doing this.  I've been an RNAC for a long time and this is the first time I have encountered this.  The documentation is HORRIBLE.   Thanks for the imput in advance   To admit you were wrong is to declare you are wiser now than before. --Unknown