Re: Quarterly Notes

[Jamie Morris, RN]

We provide a copy of the MDS schedule to the hall nurses and they are required to chart 7 days prior to the ARD, each shift. We did an in-service & instructed what items to cover based on the MDS (ex. day 1, chart on cognitive & communication & activity attendance, etc) and provided the LPN's with terms & definitions from the MDS to be consistent. This has worked well for us except for mood/behavior... they say "frequently anxious" or "combative at times", so we are working on this... ----- Original Message ----- From: [EMAIL PROTECTED] To: [EMAIL PROTECTED] Sent: Friday, December 05, 2003 2:22 PM Subject: Re: Quarterly Notes 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